. •:::•. 




Class JB£___ 

Book. ■ J 

Copyright^ 



COPYRIGHT DEPOSE 



LIST OF CONTRIBUTORS. 



BARTLEY, ELIAS H., B. S., M. D. 
BRISTOW, ALGERNON T., A.M., M.D. 
BUCKMASTER, AUGUSTUS H., M.D. 
CAMERON, J. CHALMERS, M.D. 
CHAPIN, HENRY DWIGHT, M.D. 
CROCKETT, MONTGOMERY A., A.B., M.D. 
DICKINSON, ROBERT L., M.D. 
EDGAR, JAMES CLIFTON, M.D. 
HAMILTON, ALLAN McLANE, M.D. 
HENROTIN, FERNAND, M.D. 
JEWETT, CHARLES, A.M., M.D. 
MANTON, W. P., M.D. 
PALMER, CHAUNCEY D., M.D. 
POLAK, JOHN O., B.S., M.D. 
ROBB, HUNTER, M.D. 
VAN COTT, JOSHUA M., Jr., M.D. 
VINEBERG. HIRAM N., M.D. 
WEBSTER, J. CLARENCE, M.D. 
WILLIAMS. J. WHITRIDGE. M.D. 



/ 



THE 






PRACTICE OF OBSTETRICS 



BY 



AMERICAN AUTHORS 



EDITED BY 

CHARLES JEWETT, M.D., 

PROFESSOR OF OBSTETRICS AND GYNECOLOGY IN THE LONG ISLAND COLLEGE HOSPITAL, NEW YOK1 

SECOND EDITION, REVISED AND ENLARGED. 

ILLUSTRATED WITH 445 ENGRAVINGS, 48 OF WHICH ARE EN 
COLORS, AND 36 COLORED PLATES. 




LEA BROTHERS & CO., 

NEW YORK AND PHILADELPHIA. 



~^& 50,4- 



THE USftARY OF 
CONGRESS, 

Two Copies Received 

NOV, 4 1901 

Copyright entry 

tLASS «>XXo, No. 
^^ 33 & 
COPY A. 



Entered according to the Act of Congress in the year 1901, by 

LEA BROTHERS & CO., 

In the Office of the Librarian of Congress. All rights reserved. 



DOENAN, PRINTER. 



PREFACE TO THE SECOND EDITION. 



That the first edition of this work, published two years ago, has 
been exhausted within so short a time, is gratifying evidence of pro- 
fessional approval. In the present edition extensive revisions have 
been made and many new illustrations have been introduced, most of 
them original. Among the more important alterations are those per- 
taining to the pathology of pregnancy and to obstetric surgery. 

The work of our late colleague Dr. W. W. Browning has been 
taken up by Dr. A. T. Bristow. Important changes have been made 
in the text of this chapter to conform to recent developments, and 
it has been enriched with new and original plates in colors and in 
black and white. 

Two of the chapters originally contributed by the late Dr. J. H. 
Etheridge have been rewritten by Dr. M. A. Crockett, and the other 
three have been rewritten by the Editor. 

Acknowledgment is due the original authors for their continued 
interest in the work and to those w T ho have reinforced the corps of 
contributors. The Editor is indebted to Dr. C. R. Hyde for valuable 
assistance in revision of the chapter on Anomalies and Diseases of 
the Breasts and Nipples, and to Dr. H. P. de Forest for the skill 
and accuracy with which he has prepared the index. 

CHARLES JEWETT. 

October, 1901. 

(v) 



LIST OF CONTRIBUTORS 



ELIAS H. BARTLEY, B. S., M.D., 

Professor of Chemistry, Toxicology, and Pediatrics iu the Long Island College Hos- 
pital ; Physician to the Sheltering Arms Nursery, New York ; Pediatrist to Bush- 
wick Central Hospital ; Consulting Pediatrist to Bushwick and East Brooklyn 
Dispensary. 

ALGERNON T. BRISTOW, A.B., M.D., 

Surgeon to the Long Island College Hospital, the Kings County Hospital, and St. 
Johns Hospital ; Consulting Surgeon to the Bushwick Central Hospital and the 
Long Island State Hospital. 

AUGUSTUS H. BUCKMASTER, M.D., 

Professor of Gynecology and Obstetrics in the Medical Department, University of 
Virginia, Charlottesville ; Gynecologist and Obstetrician to the University of Vir- 
ginia Hospital. 

J. CHALMERS CAMERON, M.D., CM., M. R. C.P.I. , 

Professor of Obstetrics and Diseases of Infants in the McGill University, Montreal, 
Canada ; Accoucheur to the Montreal Maternity Hospital ; Consulting Physician 
to the Montreal General Hospital. 

HENRY D WIGHT CHAPIN, M. D., 

Professor of Diseases of Children in the New York Post-Graduate Medical School 
and Hospital ; Attending Physician to the Post-Graduate, the Willard Parker. 
and the Riverside Hospital; Consulting Physician to the Randall's Island Hospital. 
New York. 

MONTGOMERY A- CROCKETT., A. B., M.D., 

Adjunct Professor of Obstetrics and Gynecology in the Medical Department of the 
University of Buffalo; Attending Gynecologist to the Buffalo General and the 
Erie County Hospitals. 

ROBERT L. DICKINSON, M.D., 

Assistant Professor of Obstetrics and Assistant Obstetrician in the Long Island College 
Hospital; Obstetrician to the Kings County Hospital; Surgeon to the Brooklyn 
Hospital, New York. 

J. CLIFTON EDGAR, M.D., 

Professor of Obstetrics and Clinical Midwifery in the Cornell University Medical 
College: Attending Surgeon to the New York Maternity Hospital and Mothers 
and Babies Hospital. 



vm LIST OF CONTRIBUTORS. 

ALLAN McLANE HAMILTON M.D., 

Professor of Mental Diseases in the Cornell University Medical College ; Consulting 
Physician to the Manhattan State Hospital for the Insane, New York. 

EERNAND HENROTIN, M.D., 

Professor of Gynecology in the Chicago Polyclinic ; Gynecologist to St. Luke's, St. 
Joseph's, arid the German Hospital, Chicago. 

CHARLES JEWETT, A.M., M.D., Sc.D., 

Professor of Obstetrics and Gynecology in the Long Island College Hospital, and 
Obstetrician and Gynecologist to the Hospital ; Consulting Obstetrician to the Kings 
County Hospital ; Consulting Gynecologist to the Bushwick Hospital ; Consulting 
Surgeon to St. Christopher's Hospital, etc., New York. 

WALTER P. MANTON, M.D., 

Professor of Obstetrics in the Detroit College of Medicine ; Gynecologist to the Harper 
Hospital and to the Northern and Eastern Micbigan Asylum for the Insane, and 
Consulting Gynecologist to St. Joseph's Eetreat, Detroit. 

CHAUNCEY D. PALMER, M.D., 

Professor of Gynecology and Clinical Gynecology in the Medical College of Ohio ; 
Consulting Clinician in Obstetrics and Gynecology at the Cincinnati Hospital ; 
Consulting Gynecologist to the German Protestant Hospital and the Presbyterian 
Hospital, Cincinnati. 

JOHN 0. POLAK, B. S., M.D., 

Adjunct Professor of Obstetrics in the New York Post-Graduate School ; Lecturer in 
Obstetrics and Gynecology in the Long Island College Hospital ; Chief of Depart- 
ment of Gynecology in the Polhemus Memorial Clinic. 

HUNTER ROBB, M.D.. 

Professor of Gynecology in the Medical Department of the Western Beserve Uni- 
versity ; Gynecologist to the Lakeside Hospital, Cleveland. 

JOSHUA M. VAN COTT, Jr., M.D., 

Professor of Pathology in the Long Island College Hospital ; Pathologist to the Long 
Island, the Brooklyn, and the Kings County Hospital, New York. 

HIRAM N. VINEBERG, M.D., 

Adjunct Gynecologist to Mount Sinai Hospital ; Attending Gynecologist to St. Marks 
Hospital and to the Montefiore Home for Invalids. 

J. CLARENCE WEBSTER, B.A, M. D. (Edin.), RRC.P.E, 

Professor of Obstetrics and Gynecology in Bush Medical College (affiliated with the 
University of Chicago) ; Obstetrician and Gynecologist to the Presbyterian Hos- 
pital ; Obstetrician to tbe Chicago Lying-in Hospital and Dispensary. 

J. WHITRIDGE WILLIAMS, M.D.. 

Professor of Obstetrics in the Johns Hopkins University, Baltimore ; Obstetrician in 
Chief to the Johns Hopkins Hospital ; Gynecologist to the Union Protestant 
Infirmarv. 



CONTENTS 



PART I. 
ANATOMY. 

CHAPTER I. 

PAGE 

The Female Pelvic Organs— The Mammary Glands 17 

By Algernon T. Bristow, M. D. 



PAET II. 
PHYSIOLOGY OF PREGNANCY. 

CHAPTER II. 

Menstruation — Ovulation— Development of the Ovum . . .71 
By Walter P. Manton, M.D. 

CHAPTER III. 

Changes in the Maternal Organism Caused by Pregnancy . .117 
By Chauncey D. Palmer, M.D. 

CHAPTER IV. 

Diagnosis of Pregnancy 126 

By Robert L. Dickinson, M.D. 

CHAPTER V. 

Duration of Pregnancy— Evidence of Previous Pregnancy . . 14i> 
By Chauncey D. Palmer, M.D. 

CHAPTER VI. 

Hygiene and Management of Pregnancy L52 

By Chauncey D. Palmer, M.D. 

(ix) 



x CONTENTS. 

PART III. 
PHYSIOLOGY OF LABOR. 

CHAPTER VII. 

PAGE 

The Mechanical Elements of Labor 157 

By Charles Jewett, M.D. 

CHAPTER VIII. 

The Mechanism and Clinical Course of Normal Labor . . . 192 
By Augustus H. Buckmaster, M.D. 

CHAPTER IX. 

The Management of Normal Labor 211 

By Charles Jewett, M.D. 



PART IV. 
PHYSIOLOGY OF THE PUERPERIUM. 

CHAPTER X. 

The Puerperal State and its Management — The Care of the 

Puerperal Woman 249 

By Hunter Robb, M.D. 

CHAPTER XI. 

The New born Child and its Management 267 

By Elias H. Bartley, M.D. 



PART V. 
PATHOLOGY OF PREGNANCY. 

CHAPTER XII. 

Multiple Pregnancy . . . 299 

By Walter P. Manton, M.D. 

CHAPTER XIII. 

Anomalies and Diseases of the Foztal Appendages .... 303 
By Montgomery A. Crockett, M. D. 



CONTENTS. xiii 

CHAPTER XXX. 

PAGE 

The Induction of Abortion and of Premature Labor — Retained 

and Adherent Placenta 661 

By Hunter Robb, M. D. 

CHAPTER XXXI. 
The Forceps 675 

By Charles Jewett, M.D. 

CHAPTER XXXII. 

Version 701 

By John O. Polar, M.D. 

CHAPTER XXXIII. 

Embryotomy 723 

By John O. Polak, M.D. 

CHAPTER XXXIV. 

Cesarean Section— The Porro Operation— Symphysiotomy . . 736 

By Hunter Robb, M.D. 



PLATE I. 

1, internal pudie artery; 2, 3, inferior hemor- 
rhoidal; 4, transverse perineal; 3, superficial per- 
ineal (vulvar); Q, common trunk dividing into 7, 
8, 9 ; 7, branch to body of clitoris; 8, artery to the 
bulb; 9, dorsal artery; io, n, 12, ij, 14, internal 
pudie nerve and branches; 75, anastomotic branch 
to 16, pudendal branch of 17, small sciatic nerve; 
18, terminal branches forming nervous sheath for 
clitoris; 19, terminal branch of the ilio-inguinal 
nerve. 

A, anus; C, clitoris; M, meatus urinarius ; 
L, great sciatic ligament; V, vagina; O, coccyx; 
T, tuberosity of the ischium. 

a, gluteus maximus muscle; b, sphincter am 
externus; r, ischio-coecygeal band of levator ani 
muscle; d, transversus perinei muscle, «?, bulbo- 
eavernosus muscle; g, erector elitoridis muscle; 
h, portion of perineal muscle; i, adductor magnus 
muscle; k, gracilis muscle. 




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' 



PRACTICE OF OBSTETRICS 



PART 1. 

ANATOMY 



CHAPTER I. 

THE FEMALE PELVIC ORGANS. 

The female organs concerned in reproduction are located in the pelvis. 
They are usually classified as external and internal. The external organs 
include the mons Veneris, the labia majora, the labia minora, the clitoris, 
and the vaginal orifice. To them collectively is applied the designation 
pudendum. The term " vulva " includes all of the external organs except 
the mons Veneris. The internal organs are the vagina, the vaginal bulbs, 
the uterus, the Fallopian tubes, and the ovaries. The ovaries are con- 
cerned in germination, the tubes in fecundation, the uterus in gestation, 
and the remaining organs in copulation. 

The terms " external ?? and "internal," as applied to the organs of 
generation, have no scientific value. They are retained merely for con- 
venience of description. (Plate I.) 

The Perineal Space. If the female be placed upon the back, with the 
legs flexed and the thighs flexed, abducted, and rotated outward, the 
perineal space will be exposed. Its landmarks may be made out by 
palpation. They are the tip of the coccyx, the subpubic arch, and the 
tubera ischiorum. From the pubic arch to the tuberosity of the ischium 
upon each side the boundary is bony. It consists of the descending 
ramus of the pubis and the ramus of the ischium. From the tuberosity 
of the ischium to the coccyx the boundary is an imaginary line. It 
corresponds, approximately, to the lower border of the gluteus maximus 
muscle. It should be observed that the gluteal fold does not coincide 
with this border, as is sometimes stated. 

The Mons Veneris. Above the subpubic arch is an elevated mass of 
tissue, triangular in outline. The apex of the triangle points toward the 
perineal space; the base is marked by a fold of skin extending trans- 
versely across the hypogastrium; the sides correspond with the folds of 
the groins. This is the mons Venet'is. The skin over the mons Veneris 
is thick. After puberty it is covered with a growth of coarse, curly hair, 
of a color somewhat darker than that upon the sealp. Underlying the 



18 ANATOMY. 

skin is a quantity of areolar tissue continuous with the superficial fascia 
of the abdomen, 'of the thighs, and of the labia majora. It differs from 
the fascia? in those regions, however, in possessing greater firmness and 
elasticity — qualities imparted to it by fibrous bonds or trabecule, con- 
taining a certain proportion of elastic elements, by which it is traversed. 
The mons Veneris serves a purely mechanical purpose, and is of 
interest to the obstetrician as a landmark only. 

The Perineum. In the median line of the perineal space appears the 
anas and the cleft of the vulva. They are about 2.5 cm., 1 inch, apart. 
The area between the anus and the vuh^a is, by obstetricians, designated 
the perineum. The skin here is thin, deeply pigmented, and marked by 
a median raphe along which it is closely adherent to the underlying struc- 
tures. A raphe, less noticeable, may also be observed extending from 
the anus to the coccyx. The skin in this situation is not so deeply pig- 
mented nor so closely adherent to the underlying structures as is that 
over the perineum. 

For convenience of description the perineal area is divided by an 
imaginary transverse line into an anterior, genito-urinary, region, and a 
posterior, ischio-rectal, region. The dividing line is drawn across the 
perineum joining the tubera ischiorum; it presents a slight concavity 
toward the anus. 

The Labia Majora. Flanking the cleft of the vulva {i % ima urogenitalis) 
are the labia majora. Together they are analogous to the scrotum in 
the male. At the mons Veneris they meet, constituting the anterior 
commissure. Below they merge into the skin of the perineum. To 
the skin of the perineum limiting the cleft of the vulva the name pos- 
terior commissure has been applied. Each labium may be compared 
to a three-sided pyramid. The base is continuous with the mons pubis; 
the apex is at the perineum; one surface rests upon the pubic ramus, one 
looks outward toward the thigh, and one looks inward toward its fellow 
of the opposite side. The outer surface is convex. It is covered with 
coarse skin, over which extends the growth of hair from the mons pubis. 
The inner surface is also covered with skin, but of a different character. 
It is thin and moist and of a reddish color. It is covered with a growth 
of downy hair, to be seen upon close inspection only. Underlying the 
skin of the labium majus is a fascia containing fat. The fat is abundant 
near the mons, but diminishes toward the perineum. Continued into the 
fascia from the superficial fascia of the perineum is a stratum of elastic 
tissue. This may be traced as far as the margin of the external abdom- 
inal ring. Comparing this fascia with the dartos in the male, some 
anatomists claim to have demonstrated in it the presence of involuntary 
muscular fibres. By reason of the presence of the elastic and the mus- 
cular elements in the superficial fascia, the skin of the labium may pre- 
sent a corrugated appearance. 

The round ligament of the uterus, after emerging from the external 
abdominal ring, is usually lost in the adipose tissue of the mons. It 
may extend into that of the labium. In some cases, though rarely, it 
carries with it a fold of peritoneum. The course of a pudendal hernia 
is thus accounted for. 

At birth there is a slight gaping of the labia majora owing to their 
incomplete development. In the well-nourished adult virgin they are 



THE FEMALE PELVIC ORGANS. 



21 



usually in contact (vulva connivens), concealing from view the strue 
within. In the aged and emaciated they may gape (vulva hians), o\ 
to waste of adipose tissue. They may be pressed apart by excessiV 
development of the nymph se. 



in 



Fig. 1. 
wions veneris 




CLITORIS 



MEATUS 
URINARIU! 



Vulva of a virgin. The labia have been widely separated. (Testut.) 

The Labia Minora. By separating the labia majora the labia minora or 
nymphm may be brought into view. They are analogous to the skin of 
the penis in the male. Each nympha consists of an elongated triangular 
fold of modified integument. The bases unite medially above the clitoris, 
and the apices are lost in the labia majora at the sides of the ostium 
vaginae. Each presents two surfaces and a free border. In the undis- 
turbed condition of the parts the external surface is in contact with the 
labium majus of its own side, and the internal surface is in contact with 
the corresponding surface of the opposite nympha. At the glans clitori- 
dis the free borders bifurcate. The upper divisions unite above that 
structure, forming a hood-like covering for it, known as its pnrputium, 
and the lower divisions unite below it, constituting its framilum. The 
surfaces of the nymphre are smooth and moist. Sebaceous glands exist 
upon the external surfaces, but hairs are nearly if not quite wanting. 
Upon the internal surfaces there are no hairs, and few if any sebaceous 
glands. A peculiar cheesy material known as smegma collects beneath 



22 



ANATOMY. 



with a duct about 15 mm., § inch, in length and 3 mm., J inch, in 
diameter. This passes obliquely forward or curves round the extremity 
of the bulb to open between the labium minus and the attached border 
of the hymen. The duct at its orifice is contracted and can with diffi- 
culty be discovered. Its location, however, is usually marked by a vas- 
cular area, and may be the better revealed by pressing aside the hymen 
or the caruncula myrtiformis. 

From their location and that of their ducts, the glands of Bartholin 
are also denominated the vulvo-vaginat glands. They are active during 
sexual excitement only, at which time they secrete a yellow viscid fluid, 



Fig. 2. 




VULVO-VAGINA'. 
GLAND 



The vulvo- vaginal gland or gland of Bartholin. (The dotted line indicates the limits of the bulb of 

the vagina. (Testut.) 



which serves a purely mechanical purpose. They do not develop till 
puberty, and they become atrophied iu the aged. 

The deep perineal arteries supply the glands of Bartholin. 

The Hymen. The vaginal orifice varies in appearance in different indi- 
viduals. In the virgin it is partially closed by a structure known as 
the hymen. The hymen is a reduplication of the most inferior portion of 
the vaginal Avails. It, therefore, consists of connective tissue supporting 
bloodvessels and covered by mucous membrane. Elastic and muscular 
tissue as well as nerve-fibres may be demonstrated within it. Asa rule, 
it springs from the posterior and the lateral vaginal walls only. In 
exceptional cases the anterior wall contributes also to its formation. It, 
therefore, presents a variety of forms. (Fig. 3.) It may completely 
occlude the vagina (imperforate). It may be perforated by numerous 
small openings (cribriform). It may present a central longitudinal cleft. 
Its common form, however, is crescentic, the free concave border looking 
toward the anterior vaginal wall. Being crowded inward, it lies in folds, 
giving to it a fluted appearance. 



THE FEMALE PELVIC ORGANS. 



23 



Usually the hymen is more or less lacerated at the first coitus. (Fig. 
4.) Almost without exception it is obliterated at parturition. There- 
after nothing remains of it but fleshy tags attached about the entrance 
to the vagina. (Fig. 5.) These are called carunculce myrtiformes. 
From the medico-legal stand-point the absence of a hymen furnishes 



Fig. 3. 




CRESCENTIC 



FRINGED BILABIAL BIPERFORATE 

Different forms of hymen. (Testut.) 



CRIBRIFORM 



prima facie evidence only of sexual indulgence. The converse of this 
proposition is also true. It may be absent in the virgin, and has been 
known to persist in the parous woman. On the other hand, carunculse 
myrtiformes are undeniable evidence of a former parturition. 



Fig. 4. 



Fig. 





Hymen after coitus. (Testut.) Hymen after parturition. (Testut.) 

Fig. 4.— C. Clitoris. PL. Nymphae. U. Meatus urinarius. OV. Vaginal orifice. H. Hymen. D. 

Rent in hymen. 
Fig. 5.— U. Meatus urinarius. P. Nympha. CM. Carunculce myrtiformes. Z. Portion of hymen. 

detached and floating. D. A tear through the fourchette. 

When the hymen is intact the exposed ostium vaginae appears as a 
vertical slit. When it is destroyed the anterior and posterior vaginal 
walls are seen to be in contact. The remains of the hymen, however. 



24 



ANATOMY. 



may be traced about the orifice in a ring, which is laterally compressed 
as the vulva is allowed to close. This form of the ostium vaginae is 
maintained, no doubt, by the arrangement of the muscular fibres of the 
pelvic floor. 

The Glans Clitoridis. Just above the apex of the vestibular triangle 
may be seen the glans clitoridis surrounded by its prepuce. In the non- 
turgid condition it is a mere papilla. Frequently it is entirely hidden 
from view by an elongated prepuce. Occasionally the prepuce is adher- 
ent to it, rendering it still more difficult of demonstration. "When turgid 
during sexual excitement it is rarely as large as a small pea. 

The glans is the only part of the clitoris which is visible on inspection 
of the genitalia. It is covered by a modified skin which is extremely 
delicate and sparingly supplied with sebaceous glands. Sebaceous glands, 
however, are w r ell developed about its circumference, and secrete an oily 
substance which emits a characteristic odor. 

The Clitoris. The clitoris is not the analogue of the penis, as is so often 
stated. It corresponds rather to the glans, corpora cavernosa, and crura 
of that organ. When erect it may be felt, like a rounded cord, about 
2.5 cm., 1 inch, in length and 5 mm., |- inch, in diameter. It arches 

Fig. 6. 




The clitoris. (After Kobelt.) 

A. Bulbus vestibuli. C. Pars intermedia. E. Glans clitoridis. F. Corpus clitoridis. 

H. Dorsal vein. L. Right crus. M. Vestibule. N. Gland of Bartholin. 



upward from the apex of the vestibular triangle to the summit of the 
subpubic arch. (Fig. 6.) It consists of glans, corpora cavernosa, and 
crura, in structure similar to the corresponding parts of the penis, but 
of diminutive size. The trabecule of the cavernous bodies are firmer 
than those in the male organ. The glans is imperforate, and is formed 
of a plexus of veins continued into it from the bulbs of the vagina. It 
will be noticed that the corpora cavernosa are formed of true erectile 



THE FEMALE PELVIC ORGANS. 



25 



tissue. Not so the glans, though it becomes turgid during the erection 
of the clitoris. 

The clitoris, like its analogue, is furnished with a suspensory ligament. 
Its mobility, however, is greatly limited by the attachments of the pre- 
puce and of the frenulum. 

The vessels supplying the clitoris are disposed in the same manner as 
the corresponding ones in the male. The same may be said of the lym- 
phatic canals. The nerve-supply to the organ is proportionately much 
more abundant than that of its analogue. Its source is both from the 
internal pudic nerves and from the hypogastric plexus of the sympathetic. 
Xerves from both these sources communicate freely in the organ and 
form an especially rich network upon the glans. Their method of termi- 
nation is similar in both sexes. 

The Bulbs of the Vagina. Located at the sides of the vagina are the 
vaginal bulbs, more commonly designated the bulbs of the vestibule. 
(Fig. 7.) They are analogous to the bulbous portion of the corpus 
spongiosum in the male. They lie between the constrictor vaginae 
muscle and the anterior layer of the triangular ligament. Relying upon 
the usual illustrative drawings, one would certainly be disappointed in 
their appearance, unless an artificially injected specimen were to be 
examined. Each bulb consists of a plexus of large veins enclosed 
within a fibrous capsule. When injected it is about 2.5 cm., 1 inch, in 
length and 12 mm., J inch, at its greatest breadth. It is flask- shaped, 

Fig. 7. 




The bulbs of the vestibule. (Playfair.) 

a. Bulb of vestibule, b. Muscular tissue of vagina, c, d, e,f. The clitoris and muscles. </. h, i, k. I, m. n. 

Veins of the nymphae and clitoris communicating- with the epigastric and obturator veins. 



the bottom of the flask being on a line with the points where the labia 
minora disappear at the sides of the ostium vaginse. Anteriorly the 



26 



ANATOMY. 



bulbs taper and communicate with each other beneath the clitoris. The 
isthmus of communication is known as the pars intermedialis of Kobelt. 
The veins of the bulbs communicate freely with the plexuses of the 
nymphse and of the labia majora, and also with those making up the 
substance of the glaus clitoridis. 

The bulbs of the vagina, though becoming turgid during sexual excite- 
ment, do not constitute a true erectile tissue. When turgid they encroach 
upon the space between the pubic rami, and thus narrow the vaginal 
orifice. 

The Vagina. The vagina is usually described as a museulo-membra- 
nous canal leading from the vulva to the uterus. Lying as it does 
between the bladder and the rectum, its axis varies according to the 
fulness or emptiness of these viscera. Its axis is also dependent upon 
the condition of the pelvic floor. With the pelvic floor intact and with 
the bladder and the rectum empty, the axis of the vagina is nearly par- 
allel with the pelvic brim, except that its lower portion is bulged forward 
by the perineal body. It is evident that its axis will be rendered more 
nearly horizontal by a distended bladder and more nearly vertical by a 

Fig. 8. 




Transverse section of the lower portion of the vagina. (Henle.) 
L. Levator ani muscle. R. Rectum. U. Urethra. V. Vagina. 



full rectum. In the virgin, in whom the hymen is still intact, the 
vaginal opening appears as a vertical slit. AVhen, however, the hymen 
has been destroyed the anterior and the posterior walls of the vagina are 
seen to be in contact, and upon cross section its lower end presents an 
outline resembling the capital letter H. The ostium is much the nar- 
rowest part of the canal, even when the latter is distended. A cast of 
the distended vagina has the shape of an inverted truncated cone, and 
that this is the shape of the canal may be demonstrated by exploring it 
with the subject in the genu-pectoral position. The upper expanded 
portion has been designated the fornix or vault. Into it from above 
projects the cervical segment of the uterus. The recesses in front of, 



THE FEMALE PELVIC ORGANS. 



27 



behind, and at the sides of the cervix uteri are distinguished as the ante- 
rior, the posterior, and the lateral fornices. 

Since the vaginal canal is usually in a collapsed condition, but two 
walls, the anterior and the posterior, demand description. From what 
has been already stated, it will appear evident that both walls are wedge- 
shaped and that the narrow extremities of the wedges are at the ostium 
vaofina3. 




Fig. 9. 
rectal peritoneum 

: POUCH 
RIOR AND POS- 
IOR LAYERS OF 
ROAD LIGAMENT 

VESICAL 
PERITONEUM 

VESICO-UTERINE 
POUCH 



The neck of the uterus and the upper extremity of the vagina, showing their relation to the peri- 
toneum (vaginal walls in red). (Testut.) 

The capacity of the vagina is increased in every direction by child- 
bearing. In parous women it may have its greatest breadth through the 
middle; but, as a rule, it is broadest at the fornix. This breadth varies 
from 3.5 cm., 1J inch, in nulliparae to double this measurement in mul- 
tipara?. The length of the vagina varies in the different races and in 
different individuals of the same race. In the negress it is longer as 
well as more capacious than in women of the white race. Measurements 
are made along both the anterior and the posterior walls. The average 
length of the anterior vaginal wall in white women is 6 cm., 2h inches, 
and of the posterior wall 8.5 cm., 3J inches. The canal is not quite as 
long in virgins, and it undergoes shortening in senile involution. Cases 
of congenital shortening are not infrequently met with in which the canal 
is diminished to half its usual length. The difference in the lengths of 
the anterior and of the posterior vaginal walls may create the erroneous 
impression that the cervix uteri projects through the upper part of the 
anterior wall, and this impression is strengthened by the greater depth 
of the posterior fornix. 

The vagina is a muscular organ lined by mucous membrane and sur- 
rounded by dense areolar tissue. This has led anatomists to describe it 
as having a fibrous, a muscular, and a mucous coat. Its walls vary in 
thickness from 5 mm. to 1 cm., J to J inch. They are thinnest at the 
fornix and thickest where the urethra is embedded in the anterior wall. 
This difference in thickness is confined almost entirely to the muscular 
structure. The muscle is of the nnstriated variety and has intermingled 
with its fibres a certain amount of elastic tissue. Muscular fibres may 
be made out, taking various courses, circular, longitudinal, and oblique. 
They interlace, however, in so intricate a manner as to be inseparable 
into distinct strata. Thev are continued into the muscular walls of the 



28 



ANATOMY. 



uterus above, and below are lost in the structure of the pelvic floor. It 
is a mistake to state that they are attached to the bony pelvis. 



Fig. 10. 




^Igr 



Longitudinal section of the vagina. (Testut.) 
a. Segment showing posterior wall. b. Segment showing anterior wall. 

The mucous membrane of the vagina is continuous with that of the 
uterus, and, inferiorly, it covers the hymen and the vestibule. Its 
epithelium is of the pavement variety. This variety of epithelium char- 
acterizes the mucous membrane of the intravaginal surface of the cervix 
uteri also. The vaginal mucous membrane is from 1 mm. to 1.5 mm. 
in thickness, and is closely adherent to the underlying muscular wall. 
In the lower half of the canal each wall is marked by a longitudinal 
median elevation or furrow — the columna vagince. This is flanked by 
transverse ridges — the rugce or aistce vagince. The column upon the 
anterior wall is most marked and seems to originate in the prominent 
mass of tissue surrounding the urethral opening. The crista?, which are 
also best developed upon the anterior wall, are not to be considered as 
folds of the mucous membrane. They are not obliterated when the 
vagina is put upon tension, and are, no doubt, due to an alternate thick- 
ening and thinning of the mucosa. The markings upon the vaginal 
walls are most distinct in the infant and in the virgin. They are obscured 
by childbearing and by catarrhal inflammation. 



THE FEMALE PELVIC ORGANS. 



29 



A sparing secretion of mucus, acid in reaction, is found upon the 
vaginal walls. Its source is undetermined, since no glands have been 
demonstrated in the mucosa. The reaction of the secretion has been 
supposed to be due to the presence in it of an organism known as the 
bacillus of Doderlein. Recent investigation, however, has rendered this 
theorv doubtful. 



Fig. 11. 




Sagittal section of the uterus to show the manner in which the peritoneum is attached. 
a. Body of the uterus, a'. Anterior surface, a". Posterior surface, b. Neck. c. Isthmus. 1. Cavity 
of the body. 2. Os internum. 3. Os externum. 4. Posterior fornix. 5. Anterior lip of cervix. 6. 
Anterior vaginal wall. 7. Posterior vaginal wall. 8. Vesico-uterine septum. 9. Wall of the bladder. 
10. Peritoneum. 11. Vesico-uterine pouch. 12. Cul-de-sac of Douglas. (Testft.) 



The muscular walls of the vagina are surrounded by fibro-cellular 
tissue. This serves to support a rich vascular network. The relation 
of the vagina to the tissues forming the pelvic floor has already been 
considered. A short distance above this floor the posterior vaginal wall 
comes in close contact with the rectum. This relation is maintained up 
to the line where the rectum receives its peritoneal covering. The struc- 
tures between the two canals constitute the rectovaginal septum. Ante- 
riorly the vaginal fornix and the upper part of the canal itself are sepa- 
rated from the urinary bladder by a mass of loose connective tissue. This 
supports the vesico- vaginal plexus of vessels. The relation of the vagina 
to the urethra has been already described. The structures between the 
bladder and the vagina constitute the vesicovaginal septum. Those 
between the lumen of the vagina and that of the urethral canal form the 
urethrovaginal septum. Laterally the walls of the vagiual fornix arc 
in relation with the bases of the broad ligaments. 

From the foregoing description and that which has already been given 
of the vesico-uterine pouch it will be understood that the anterior fornix 
is separated by a considerable distance from the peritoneal cavity. Pos- 
teriorly, however, the peritoneum is reflected from the anterior rectai 
wall forward and upon the vagina. Thence it takes a course upward 
and to the uterus. The posterior vaginal wall below its attachment to 
the uterus is thus covered for a certain distance by peritoneum. This 
distance varies in length from 15 mm. to 3 cm., J to 1]- inch. Thus 



30 ANATOMY. 

the posterior fornix is in close relation to a peritoneal recess between the 
rectum and the vagina, designated the recto-vaginal pouch or cul-de-sac 
of Douglas. Laterally the cul-de-sac is bounded by peritoneal folds 
reaching from the upper part of the cervix uteri to the sides of the 
rectum and past the rectum to the second sacral segment. These are 
the folds of Douglas or the utero-sacral ligaments. 

In congenital shortening of the vagina copulation is difficult. How- 
ever, the posterior wall of the vagina may become elongated by repeated 
acts of sexual congress, thus greatly distending the posterior fornix. 

Prolapsus uteri and congenital shortening of the vagina should not be 
mistaken the one for the other, since in simple prolapsus the uterus may 
readily be replaced. 

The Ischio-rectal Fossa. The ischio-rectal fossa in the female is broader 
and shallower than in the male; otherwise the anatomy of both is the 
same. Its form is pyramidal. It is bounded anteriorly by the perineal 
ledge, externally by the obturator fascia, and superiorly and internally 
by the anal fascia. It contains firm, coarse areolar tissue of low vascu- 
larity and, on that account, is frequently the seat of abscesses. This 
region is of practical interest to the obstetrician in so far only that in 
very fat women it may obstruct delivery. 

It should be remembered that terminal branches of the pudic arteries 
and nerves approach the anus from before backward, crossing the external 
sphincter obliquely. 

The Anus. About 2.5 cm., 1 inch, below the posterior commissure of 
the vulva appears the anus. It is the orifice of the bowel. The skin 
about the anus is exceedingly delicate and deeply pigmented. It is 
abundantly supplied with sebaceous glands and covered w 7 ith a growth 
of hair. The hair does not grow as profusely, however, as in the male. 
The skin of the anus is prolonged into the bowel about 1 cm., \ inch. 
Owing to the presence in it of unstriated muscular fibres, it is thrown 
into radiating folds and presents a puckered appearance. To the mus- 
cular fibres has been given the name corrugator cutis ani. 

The subcutaneous veins at the junction of the skin and the mucous 
membrane of the bowel are loosely supported. For this reason they 
frequently present varicose enlargements and protrude as external piles. 
The remains of these tumors may persist about the anus in the form of 
fleshy tags. 

The Rectum. The rectum is that part of the intestinal tract which 
extends from the pelvic brim to the anus. At its commencement it lies 
upon the left sacro-iliac synchondrosis. Throughout its course it pre- 
sents three well-marked curves. It first curves downward, backward, 
and toward the right to the hollow of the sacrum. Thence it curves 
forward to reach and to become attached to the posterior vaginal wall. 
It then leaves the vagina, from wdiich it is separated in the rest of its 
course by the perineal body. The three curves are in length 9 cm., 7.5 
cm., and 4 cm. respectively. The entire length of the canal is, there- 
fore, about 20. 5 cm. , 8 inches. The rectum when empty occupies little 
of the pelvic space, but is capable of great distention. When distended 
at the time of parturition it may present an obstacle to delivery. Its 
most dilatable part is about 2.5 cm., 1 inch, above the anus, and is desig- 



THE FEMALE PELVIC ORGANS. 



33 



The Superficial Fascia of the Perineum. The superficial layer of the 
superficial fascia of the aual aud that of the genito-urinary regions are 
continuous with each other aud with that of the rest of the body. In 
the genital area of the perineal space a deep layer of the superficial fascia 
may be demonstrated. It corresponds to Colles ? fascia in the male. It 
is attached to the anterior margins of the descending rami of the pubes, 
and is continued upon the rami of the ischia as far as the tuberosities. 



Fig. 13. 




Muscles of the pelvic floor. (Modified, from Savage.) 
A. Anus. B. Bulbs of the vestibule. C. Coccyx. G. Glaus clitoridis. U. Meatus urinarins. V. 
Vagina. D. Glands of Bartholin, a. Ischio-cavernosus muscle, b. Bulbo-caveruosus. c. Trans- 
versus perinei. d. Sphincter aui. e. Levator ani. /. Coccygeus. g. Gluteus rnaxiuius. /;. Obtu- 
rator externus. 



Toward the central line it enters the labia majora, and in them may be 
traced to the external abdominal rings. Posteriorly it turns around the 
transversus perinei muscles to join the deep fascia. The deep fascia. 

3 



34 AXATOMY. 

otherwise known as the anterior or inferior layer of the triangular liga- 
ment, will be described hereafter. 

To expose the remaining muscles of the perineum the deep layer of 
the superficial fascia must be removed. 

The Constrictor Vagina Muscle. The constrictor vagince muscle (some- 
times also called the sphincter vagince) is the analogue of the accelerator 
urinae or bulbo-cavernosus in the male. It exercises no such function 
as its name would suggest, but rather compresses the bulbs of the vagina, 
which it covers. The muscle consists of thin sheets of striated fibres 
located upon the sides of the vaginal opening which it thus surrounds. 
The fibres arise at the perineal body, being closely related to those of 
the external sphincter ani and of the transversus perinei muscles. Pass- 
ing over the vaginal bulbs they converge somew T hat and are inserted into 
the sheaths of the corpora cavernosa in front of the insertions of the 
erector clitoridis muscles. A slip crosses the clitoris and compresses the 
dorsal vein. It is claimed by Henle that some fibres may be traced into 
the posterior surfaces of the vaginal bulbs and some into the floor of the 
vestibule. The constrictor vaginae muscle is separated by a considerable 
interval from the vaginal walls. 

The Transversus Perinei Muscles. The transversus perinei or ischio-bul- 
bosus muscles correspond to those of the same name in the male. They 
differ in that they are relatively smaller in the female. Each muscle 
arises from the inner surface of the ramus of the ischium just above the 
tuberosity and between the origins of the obturator internus and the 
erector clitoridis muscles. It is inserted into the base of the perineal 
body. The fibres intermingle at their insertion with those of the other 
muscles meeting at this point. A few fibres deeply situated are inserted 
in the vaginal wall and some join their fellows from the opposite side in 
front of the urethra. These latter are sometimes separately named the 
deep transversus perinei muscles. 

The Erector Clitoridis Muscles. Internal to the origins of the trans- 
versus perinei muscles and somewhat nearer to the tuberosities of the 
ischia arise the erector clitoridis or ischio-cavernosus muscles. They are 
of reduced size as compared with their analogues, the erectores penis. 
As its name indicates, each is inserted into the corpus cavernosum. It 
is also inserted into the suspensory ligament. In its course it lies near 
the ramus of the ischium and the descending ramus of the pubis. 

The Perineal Ledge. In the triangular intervals left upon each side 
between the three last-described muscles may be seen the deep fascia of 
the perineum. As has been already stated, it is also called the anterior 
or inferior layer of the triangular ligament. It consists of a sheet of fascia 
attached laterally to the ischiatic and the pubic rami and anteriorly to 
the pubic arch, Posteriorly to the transversus perinei muscles it unites 
with the deep layer of the superficial fascia. At their line of union 
these fasciae are joined by the fascia lining the under surfaces of the 
levator ani muscles. Thus is formed the perineal ledge. The inferior 
or anterior layer of the triangular ligament is perforated by the vagina 
and the urethra, between which canals it sends a slip across the vesti- 
bule. It is, for this reason., a much weaker structure in the female than 
in the male. 



THE FEMALE PELVIC ORGANS. 



35 



The Pelvic Fasciae. An almost complete partition exists between the 
superficial structures of the pelvic floor and the viscera of the pelvis. 
It is formed by sheets of fascia and by the levator ani and coccygeus 
muscles. Since its lateral halves are symmetrical, but one side will be 
described. 

Fig. 14. 




Coronal section of the pelvis. (Browning.) 
A. Ilium. P. Ischium. C. Acetabulum. D. Psoas magnus muscle. E. Obturator externus. F. 
Levator ani. G. Sphincter ani externus. a. Transversalis fascia, b. Iliac fascia, c. Obturator 
fascia, d. '•' White line." e. Recto-vesical fascia, f. Alcock's canal. 



The obturator internus muscle arises from the lateral pelvic wall. It is 
attached to all but a small portion of the lower part of the obturator mem- 
brane. It has also a bony origin from the ramus of the ischium and the 
descending ramus of the pubis contiguous to the obturator foramen and 
from the bodies of the ischium and of the ilium. From this extensive 
origin its fibres converge to a tendon which leaves the pelvis through the 
lesser sciatic foramen. The pyriformis muscle arises from the antero- 
lateral aspect of the sacrum and passes out of the pelvis through the 
greater sciatic foramen. 

The Obturator Fascia is continuous with the iliac fascia and with that 
covering the pyriformis muscle. Above it looks toward the pelvic cavity 
and below it forms the external boundary of the ischio-rectal fossa. 
From this fascia a leaflet is given off, which takes a direction transversely 
to the pelvis. It is designated the 

Recto-vesical Fascia, or vesical layer of the pelvic fascia. The line of its 
attachment to the obturator fascia is the so-called white line. The course 



36 



ANATOMY. 



of the white line may be traced from the spine of the ischium to the pos- 
terior surface of the body of the pubis in an arc the convexity of which 
is downward. The lowest point of the arc is a little more than 5 cm., 
2 inches, below the pectineal line. By some anatomists that portion of 
the fascia covering the obturator internus muscle below the white line 
only is designated the obturator fascia, that above being described as 
part of the pelvic fascia. 

The recto-vesical fascia meets its fellow from the opposite side in a 
median raphe. Here it is perforated by the rectum and by the vagina, 
in the anterior wall of which is the lower part of the urethra. It may 
be traced into the walls of these canals. Webster has separately described 
the portion between the bladder and the vagina, that between the vagina 



Fig. 15. 




Sagittal section of the pelvis. (Browning.) 

S. Symphysis. P. Perineal ledge. 1. Superficial layer of the superficial fascia. 2. Peep layer of the 
superficial fascia (Colles' fascia in the male). 3. Anterior layer of the triangular ligament. 4. Pos- 
terior layer of the triangular ligament. 5. Eecto-vesical fascia. 

It is to be understood that these planes of fascia are perforated by the urethra, the vagina, and the 
rectum. 



and the rectum, and that posterior to the rectum as the vesico-vaginal, the 
recto -vagina/, and the rectal layers respectively. The following is taken 
also from the same author : - - Further, the arrangement of the visceral 
[recto-vesical] fascia in the anterior part of the pelvis is of considerable 
importance. Here the visceral [recto-vesical] layer arising from the 
back of the lower part of the pubis on each side of the middle line above 
the point of origin of the anterior fibres of the levatores ani as well as 
the attachment of the parietal [obturator] fascia passes backward as two 
strong bands above them and on each side of the urethra, to become 
blended with the auterior surface of the bladder. These are the anterior 



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THE FEMALE PELVIC ORGANS. 37 

true ligaments of the bladder. Between them is a space filled with loose 
connective tissue and fat, continuous below with the retro-pubic fat and 
above with the suprapubic or retro-peritoneal fat." 

Just external to the anterior true ligaments, as above described, por- 
tions of the recto-vesical fascia are reflected upon the bladderas its lateral 
tnce ligaments. 

Fig. 16. 




Drawing from a cast of a dissection made at the Long Island College Hospital. (Browning.) 
1. Rectum. 2. Coccyx. 3. Labium minus. 4. Sphincter ani externus. 5. Fibres of the levator ani 
arising from the os pubis. 6. Fibres arising from the triangular ligament. 7. Fibres arising from the 
" white line." 8. Fibres arising from the spine of the ischium. 

The Superior or Posterior Layer of the Triangular Ligament. From the 
obturator fascia along its attachment to the ramus of the ischium and to 
the descending ramus of the pubes a fascia is derived which meets its 
fellow in the median line. It is superficial to the levator ani muscle and 
blends with its sheath. In the middle line it is continued into the sheath 
of the vagina and unites with the recto-vesical fascia. By union with 
the corresponding structure of the opposite side a triangular sheet is 
formed which is perforated by the vagina and the urethra. Its apex is 
at the subpubic arch and its base joins the anterior or inferior layer of 
the triangular ligament at the perineal ledge. To this structure, weak 
in character, has been given the name superior' or posterior layer of the 
triangular ligament. 

The Levator Ani Muscle. Underlying (/. e., superficial to) the recto- 
vesical fascia is the levator ani muscle. Respecting its origin anatomists 
are practically agreed, but the direction of its fibres and their insertion 
has been variously described. It arises from the intrapelvic surface of 
the body of the os pubis and from the posterior layer of the triangular 
ligament, from the spine of the ischium and from the whole length of 
the white line. The fibres arising from the pubis, those from the white 



38 



ANATOMY. 



line, and those from the ischium are sufficiently distinct as to their arrange- 
ment and as to their insertion to entitle them to separate description if 
not to entitle them to be considered separate muscles. The area of pubic 
origin is located about 12 mm., \ inch, from the symphysis and 3.5 cm., 
\\ inch, below the upper border of the bone. The fibres arising here 
are joined by those from the posterior layer of the triangular ligament. 
This latter structure blends with the obturator fascia along the descend- 



FIG. 17. 




Drawing from a photograph of a dissection made at the Long Island College Hospital. (Browning.) 
1. Symphysis. 2. Coccyx. 3. Anus. 4. Superficial fibres from the pubic origin of the levator ani. 
5. Deeper fibres from the pubic origin. 6. Fibres from the " white line." 7. Fibres from the spine of 
the ischium. 8. Gluteus maximus muscle. 



ing pubic ramus. It will thus be seen that the origin of the pubic 
portion of the levator is more extensive than usually described and that 
its plane is superficial to and intersects that of the portion arising from 
the white line. The fibres, arising as above described, soon gather to 
form a band, about 12 mm., J inch, wide and 3 mm., \ inch, thick, and 
distinctly separable from the rest of the muscle. It takes a course nearly 
horizontally backward toward the anus. At its insertion it is bilaminar. 
The superficial fibres are continued into the sphincter ani externus, of 
which they become a part. Of the deeper fibres a few turn forward into 
the perineal body. By far the greater number take a backward course. 



THE FEMALE PELVIC ORGANS. 



39 



Posterior to the rectum they come in close contact with their fellows from 
the opposite side, bat do not join them, as is sometimes stated, either 
with or without the intervention of tendon. Most can be traced to the 
coccyx, though some fall short thereof, ending in the sheath of the muscle. 
As the pubic band sweeps by the vagina it is 5 mm., J inch, distant there- 
from. A few stray fibres from its lowermost origin, by no means con- 
stant, cross above the band and terminate in the vaginal wall. They 
correspond to the levator prostata in the male. 

Fig. 18. 




Drawing from a photograph of a dissection made at the Long Island College Hospital ; individual 

fibres of the levator isolated. (Browning.) 

1. Symphysis pubis. 2. Coccyx. 3. Anus. 4. Deep fibres from pubic origin. 5. Fibres from fascial 

origin. 6. Fibres from ischial spine. 7. White line. 8. Gluteus maximus muscle. 

The fibres from the ischium arise from the inner aspect of the spine 
contiguous to and just in front of the coccygeus muscle. They form a 
spindle-shaped bundle, thicker, somewhat more superficial than, and dis- 
tinctly separable from the fibres of fascial origin. They may also be 
distinguished by their darker color. The course of the bundle is nearly 
transverse, and it is for the most part inserted into the fourth coccygeal 
segment. A few superficial fibres turn forward upon the recto-coccy- 
geal raphe. 

The portion of the levator intermediate between those already described 
is thin and membranous. It consists of a number of fascicles which 
arise from a fascia weakly attached to the white line. Even in well- 
developed women the fascicles exhibit fascial intervals. In the aged 
and emaciated they undergo a marked degree of atrophy and degenera- 
tion. Their direction is downward, backward, and inward with varying 
obliquity toward the rectum and the recto-coccygeal raphe. The anterior 
are the most oblique and the posterior are nearly transverse. As they 
approach the rectum and the raphe they turn backward and course in a 
direction nearly parallel with the median line; most of them reach the 
coccyx ; some become aponeurotic before doing so. 1 

1 The late Prof. Browning regarded the levator ani as a rudimentary muscle. 



40 



ANATOMY. 



The levator ani muscle is lined by a thin fascia which adheres closely 
to it. It is known as the anal fascia. On the other hand, it can be 
readily dissected from the recto-vesical fascia. When thus dissected a 
delicate fascia may be demonstrated upon the upper surface of the muscle. 
This with the anal fascia constitutes its sheath. In the median line, 
extending from the rectum to the coccyx, the sheath of the levator ani 
muscle blends with the recto-vesical fascia forming the recto-coccygeal 
raphe. At the perineal body also and at the sides of the vagina and of 
the rectum these structures blend. This has led some authors to erro- 
neously describe the levator as inserted into the walls of the rectum and 
of the vagina. 

The recto-vesical fascia constitutes a support for the pelvic contents. 
By the contraction of the levatores ani this support is raised and the 
pelvic viscera elevated. The post- vaginal structures are also drawn for- 




Drawicg from a photograph of the dissection of the pelvis of a young primipara just after parturition. 

The levator ani cleaned and intrapelvic pressure removed. (Browning.) 

1. Symphysis. 2. Coccyx. 3. Anus. 4. Tuberosity of the ischium. 5. Fibres from pubic origin. 

6. Fibres from " white line." 7. Fibres from the spine of the ischium. 

ward. A very noticeable result of traction upon the pubic band is to 
evert the anus. 

Those who have conducted investigations upon the lower animals will 
have observed the proportionately greater development of the levator 
ani in those possessed of a tail, and that its function in such animals is 
almost entirely to act upon that structure. 

The triangular interval between the posterior border of the levator 
ani muscles and the anterior border of the pyriformis is filled in by the 
coccygeus. This is a thin muscular sheet. It arises from the spine of 
the ischium, and, spreading out fan-shaped, is inserted into the side of 
the coccyx and of the sacrum adjoining. 

Savage, in his description of the pelvic floor, gives to the pubic portion 
of the levator the name " pubo-coccygeus;" to the rest of the muscle the 



THE FEMALE PELVIC ORGANS. 



41 



name "obturato-coceygeus," and to the coccygeus the name " ischio 
eoocygeus." 

The Perineal Body. It is unfortunate that the term "perineum," 
when treating of the female, is used somewhat ambiguously. By anato- 
mists it is applied without distinction of sex to the whole perineal area. 
By obstetricians and gynecologists it is, as a rule, applied only to that 
span of tissue intervening between the anus and the posterior commissure 
of the vulva. This source of confusion is not cleared up by designating 
this latter area " the perineum proper." What obstetricians call the 
perineum or perineum proper corresponds to the central tendinous point 
in the male. 

Fig. 20. 




The external genitals, as seen in mesial section. (Henle.) 

a. Anus. b. Perineal body. c. Vagina, d. Urethra, e. Labium minus. /. Clitoris, g. Fossa navicu- 
laris, in front of which is the hymen. 

It has already been shown that underlying the skiu and the superficial 
fascia of this limited space several muscles intermingle their fibres. 
They are the sphincter ani externus, the constrictor vagina?, and the 
tran versus perinei. By the union of the deep layer of the superficial 
fascia and the deep fascia of the perineum (anterior layer of the trian- 
gular ligament) a strong resisting band (the perineal ledge) is formed. 
This stretches between the tuberosities of the ischia, and in crossing meets 
the anterior limit of the external sphincter ani muscle. These structures 
meeting at the central point of the perineum, together with the areolar, 
elastic and involuntary muscular tissue disposed between and about them, 
form the larger and by far the most important part of what has been 
designated the perineal body. 

It has already been stated that the rectum and the vagina, though 
opening at a distance from each other of 2.5 cm., 1 inch, come in 
contact at about 4 cm., 1\ inch, from their orifices. The perineal 
body is the aggregation of tissues included between these canals below 
their contact. It is usually described as triangular in outline upon sagittal 
section and pyramidal in form. When the rectum and the vagina arc 
flaccid it is gourd-shaped rather than pyramidal. The tissues forming 
its expanded portion or base have been already described. So much of 
the body as lies above the pelvic fascia does not differ essentially in struc- 
tural character from the connective tissue disposed elsewhere among the 
intrapelvic viscera. 



42 



ANATOMY. 



The Bladder. The bladder is a hollow muscular organ lined with 
mucous membrane. It is more or less intimately counected to surround- 
ing parts by dense fibrous or by loose areolar tissue. In structure and 
function it does not differ in the sexes. It will be necessary in a work 
of the scope of this to call attention only to certain peculiarities of 
form in the female bladder and to such relations as are of interest to the 




CLITORIS — 



; agittal section of the female pelvis. (Testut.) 



obstetrician. Its capacity is stated to be somewhat less than that of the 
male bladder, though, under some circumstances, it is more distensible. 
It is interposed between the symphysis pubis in front and the uterus and 
the vagina behind. The neck surrounds the urethral opening. It, as a 
rule, is the most dependent portion of the organ when the erect position 



THE FEMALE PELVIC ORGANS. 



43 



of the body is assumed. The circular muscular fibres are here augmented 
somewhat, and the mucous membrane presents a puckered appearance. 
To the reinforced circular fibres has been given the name sphincter vesicas. 
This name, however, is misleading, since there exists here no true sphinc- 
ter. The term "neck" is also unfortunate in the description of the 
bladder, for the reason that the entrance of the urethra is abrupt and 
not gradual. The uvula is less distinct and the trigone is smaller than 
in the male bladder. The triangle, at the angles of which are located 
the urethral opening and the ureteric orifices, is more nearly equilateral, 
each leg measuring about 3.5 cm., 11 inch. 

At a variable distance above the pubic bone the peritoneum is reflected 
from the anterior abdominal w r all to the summit of the bladder. The 
space under this membrane and between the anterior bladder-wall and 
the pubes is known as the cavity of Retzius. It is occupied by a mass of 
loose areolar tissue which allows considerable mobility to the viscus. 

Fig. 22. 




x. Plane of pelvic outlet, y. Plane of pelvic inlet. 1. Symphysis. 2. Sacrum. 3. Rectum. 4. Uterus. 
5. Vagina. 6. Bladder. 9. Sigmoid flexure of the colon. 10. Utero-sacral ligament. (Testut.) 

Posteriorly the bladder is connected with the upper part of the vagina 
and with the cervix uteri by a firmer connective tissue. From the 
summit of the bladder the peritoneum is reflected upon the uterus at 
about the level of the os internum, forming the vesico-uterine pouch. 

When empty the bladder sinks below the pelvic brim and the fundus 
of the uterus falls forward upon it. The vesico-uterine pouch is then 
collapsed and the intestines rest upon the posterior uterine wall. When 
distended the bladder rises into the abdominal cavity. It carries the 
uterus upward and pushes it backward, and coils of intestine may fall 
into the vesico-uterine pouch. 

The distended bladder of the adult female is ovoid, the long axis being 
transverse. That of the child and that of the aged assume more nearly 
the masculine type. When empty the bladder sinks beneath the pelvic 
brim and the uterus drops forward upon it. Upon sagittal section the 
long axis of the collapsed bladder would form nearly a right angle with 
that of the vagina. 

The Urethra and the Urethro-vaginal Septum. The urethra of the female 
is about 3.5 cm., 1 J inch, in length. Its axis is nearly parallel with the 



44 ANATOMY. 

plane of the pelvic brim. Its lower three-fourths is embedded in the 
anterior vaginal wall. Its upper fourth is separated therefrom by a 
mass of cellular tissue. The average diameter of the canal is 5 mm., 
\ inch, though it is very dilatable. Its walls are muscular and lined 
with mucous membrane. The mucous membrane is thrown into longi- 
tudinal folds by the presence of elastic fibres in the submucosa. The 
muscular wall consists of two distinct strata of smooth fibres. Those of 
the internal stratum are longitudinal in direction, continuous with the 
longitudinally disposed fibres of the bladder: The external stratum is 
continuous with the sphincter vesicae. In the upper fourth of the urethra 
the external fibres encircle the canal. In its lower three-fourths they 
may be demonstrated anteriorly to it only, being continuous posteriorly 
with the circular fibres of the vagina. The striated fibres from the deep 
transversus perinei muscles which meet in front of the urethra are some- 
times described as the compressor uretlirce or Guthrie s muscle. Some 
investigators claim to have demonstrated the presence of voluntary fibres 
encircling the upper part of the canal, which they contend act as a vol- 
untary sphincter. The arraugement of the sphincter vagina? of Luschka, 
wherebv the urethra is compressed against the urethro- vaginal septum 
has already been alluded to. 

The urethro-vaginal septum may be nearly or quite 1.5 cm., J inch, 
in thickness in the lower three-fourths. Above, the canals are more 
widelv separated by the interposition of cellular tissue. An idea of 
the relative position of the parts, as well as of the thickness of the 
septum, may be gained from the following statement : If a line be drawn 
from the middle of the posterior surface of the symphysis pubis to the 
cervix uteri, its length would be about 5 cm., 2 inches, and the vesical 
opening of the urethra would be located at about the union of the ante- 
rior and middle thirds. Quain states that the female urethra corresponds 
to the prostatic portion in the male. There seems, however, to be no 
ground for making so definite a statement. 

Throughout, the mucous membrane of the urethra presents the orifices 
of tubular glands. Two tubules, much larger than the rest, open upon 
the floor of the urethra near the meatus. Their mouths are not readily 
discernible, except under pathological conditions. They are known as 
Skene's glands. 

Development of the Sexual Organs. At the beginning of the seventh 
week the embryonic structures from which the reproductive organs are 
to be developed present the same appearance in both sexes. The intes- 
tinal and genito-urinary canals discharge into a common chamber or 
cloaca. Just within the cloaca, anteriorly, is an elevation of tissue repre- 
senting the future external organs of generation. The canal leading to 
the bladder is comparatively large and is known as the uro-genital sinus. 
In the lumbar region are two glandular structures, one upon each side. 
They are the Wolffiari bodies. From their lower extremities the Wolffian 
ducts lead inward and downward to the uro-genital sinus. Upon each 
side another tubular structure may be observed. Above, it lies upon the 
external surface of the Wolffian body. At the lower extremity of the 
Wolffian body it crosses the Wolffian duct, from without inward, and, 
turning downward, runs along its inner side to reach the uro-genital 
sinus. This is the duct of Midler. Medially the lower portion of the 



THE FEMALE PELVIC ORGANS. 



45 



Fig. 23. 



ducts of Miiller are in contact. Subsequently the partition between 
them disappears, and the single tube, thus resulting, becomes the " foun- 
dation of the vagina and uterus in the female, and the prostatic vesicle 
or uterus masculinus in the male; 
the upper or forepart of the Mul- 
lerian duct disappears in the male ; 
in the female it forms the oviduct' ' 
(Quain). Arrest of development 
will explain the congenital mal- 
formations of double uterus and 
double vagina. 

The reproductive gland (testicle 
or ovary) is developed from the 
Wolffian body. The Wolffian body 
is held to the posterior abdominal 
wall by a reflection of peritoneum 
from which a fold passes down- 
ward to the groin. After the atro- 
phy of the parent structure its peri- 
toneal investment forms the meso- 
varium or mesorchium, as the case 
may be, and the descending fold 
(plica gubernatrix) becomes the 
gubernaculum testes in the male 
and the round and ovarian liga- 
ments in the female. The Wolffian 




didymis, disappears, for the most 
part, in the female. A remnant, 
however, corresponding to the 
globus major, persists as a rudi- 
mentary structure, and is described 
under the name of the parovarium 
or epoophoron. 



Diagram of the primitive urogenital organs in 
the embryo previous to sexual distinction. The 
duct, which in the male develops parts are shown chiefly in profile, but the Miiller- 
into the Vas deferens and the epi- ^ and Wolffian ducts are seen from the front 3. 

Ureter. 4. Urinary bladder. 5. Urachus. ot. The 
mass of blastema from which ovary or testicle is 
afterward formed. W. Left Wolffian body. x. Part 
at the apex fiom which the coni vasculosi are 
afterward developed, w, w. Right and left Wolffian 
ducts, m, to. Right and left Mullerian ducts unit- 
ing together and with the Wolffian ducts in gc, the 
genital cord. ug. Sinus urogenitalis. i. Lower 
part of the intestine, cl. Common opening of the 
intestine and uro-genital sinus, co. Elevation 
As is the Case with the testis, SO which becomes clitoris or penis. Is. Ridge from 
the OVarv migrates Its descent wn i cn tne labia majora or scrotum are formed. 

is arrested, however, by the plica 

gubernatrix becoming attached to the Mullerian duct. This accounts 
for the permanent location of the ovaries and for the attachment of the 
ovarian and the round ligaments to the uterus. 

The Fallopian Tubes. The Fallopian tubes, for the reason that they 
conduct the discharged ova to the uterine cavity, have been denominated 
the oviducts. They are within the folds of the broad ligaments and 
occupy their superior borders, reaching from the cornua of the uterus 
nearly to the lateral pelvic walls. They vary in length from 7.5 cm. to 
12.5 cm., 3 to 5 inches. As a rule, the right tube is somewhat the 
longer of the two. In their development the Fallopian tubes may 
be considered as finally penetrating the broad ligaments, so that they 
open into the peritoneal cavity. The broad ligaments surround them 
much as the peritoneum does the small intestine. Since to the tube is 



46 



ANATOMY. 



applied the technical name "salpinx," the designation mesosalpinx is 
given to that portion of the broad ligament included between the tube 
above and the ovary and the utero-ovarian ligament below. The appear- 
ance of the distal end of each tube is that of a ragged tear through the 
broad ligament above and just external to the ovary. From this point 
to the lateral pelvic wall the superior border of the broad ligament is 
firm and reinforced by fibrous tissue. It presents a sharply concave 
outline. It forms the ligamentum infundibulo-pelvicum or ligamentum 
suspensorium ovarii. 



Fig. 24. 







Fallopian tubes. 

U. Uterus. I. Isthmus. A. Ampulla. F. Fimbriae. F.o. Fimbria ovarica. S. Mesosalpinx. O. Ovary. 

L. Ligamentum ovaricse. P. Ligamentum infundibulo-pelvicum. E. Parovarium. (Henle.) 

It is quite evident that the position of the broad ligaments, and conse- 
quently that of the ovaries and of the tubes, will vary with that of the 
uterus. The latter organ is not firmly fixed in the pelvic cavity and its 
fundus is especially movable. Concerning the usual position of the 
uterus there has been much controversy. From the intimate connection 
of the cervix to the bladder, anteriorly, and of irs proximity to the rec- 
tum, posteriorly, it will be understood that the direction of the long axis 
of the uterus will vary according to the contents of these viscera. When 
the bladder and the rectum are both empty, the fundus of the uterus will 
drop forward so that the long axis of the uterus will form nearly a right 
angle with that of the vagina, and the uterus will sink wholly beneath 
the plane of the pelvic brim. There may also exist in the organ a cer- 
tain degree of anteflexion. The broad ligaments will now arch about 
the pelvic walls from before backward, and their uterine will be on a 
lower level than their pelvic attachments. When the bladder fills the 
fundus uteri is pushed upward and backward, and may rise above the 
plane of the pelvic brim. The long axis of the uterus becomes then 
more nearly vertical, and the broad ligaments with the uterus assume the 
position described as a transverse pelvic partition. 

When the uterus is in its anteverted position the Fallopian tubes, 
springing from its cornua, curve about the pelvic brim, superiorly to the 
ovaries, and turn downward and backward around the distal extremi- 
ties of these organs. The fimbriated extremities of the tubes are on a 



THE FEMALE PELVIC ORGANS. 



47 



level with the lower border of the ovaries, posterior to them. The 
curves in the tubes are inherent in them, aud are not due to their position 
against the pelvic walls, as may be proven by studying them when the 
uterus with its adnexa is removed from the body. 

The Fallopian tubes are muscular structures and are lined by an 
extension of the mucous membrane from the uterus. At their distal 
extremities the mucous membrane meets the serous surface of the peri- 
toneum. The muscular coat of each tube may be divided into an external 
and an internal layer. The fibres of the external layer are longitudinal 



Fig. 25. 




RTIONS OF 
IGA- 



S™ - ") ROUND L 
** L MENT 



The pelvic viscera of woman, seen from above (the left ovary and tube have been drawn up into the 

left iliac fossa) . (Testut.) 

and are continuous with the external stratum of the uterus. Those of 
the internal layer encircle the tube and are continuous with the internal 
stratum of the uterus. The circular fibres are greatly increased in number 
where the tube opens into the uterine cornu. 

The oviduct differs so much in form, in diameter, in calibre, and in 
appearance in different parts of its length, as to have led to its division 
into four portions. These are the isthmus, the ampulla, the neck, and 
the fimbriated extremity. The isthmus extends from the uterus for about 
two-sixths of the whole length of the tube. Its diameter is about 3 mm., 



48 ANA TOMY. 

\ inch. Its calibre at the uterine opening is small, admitting but a 
very fine bristle, but it gradually enlarges toward the ampulla. It has 
a solid or cord-like feel. The ampulla occupies three-sixths of the length 
of the tube, and extends from the isthmus to the neck. It is the most 
tortuous portion, the curve of which has been already described. Its 
diameter increases from the isthmus to the neck, and may reach a maxi- 
mum of 1 cm., or a little more than one-third inch. The diameter of 
its lumen is half that of the tube itself, thus rendering the ampulla less 
firm to the touch than is the isthmus. The distal sixth of the Fallopian 
tube displays a " funnel-shaped expansion surrounded by a fringe of 
peculiar fleshy processes, which recall in a striking manner the tentacles 
of a sea-anemone " (Coe). These ragged fringe-like processes are denomi- 

FlG. 26. 



'K 



A 



Left ovary turned up, showing the surface usually in contact with the broad ligament ; shows also 
the fimbria ovariea and the fimbriated extremity of the Fallopian tube. (Browning.) 
g. The ovary, h. Line of limitation between the ovary and the broad ligament, e. Fimbriated 
extremity of the Fallopian tube. M. Fimbria ovariea. The letter m' lies above the infundibulo- 
pelvic ligament, which is cut at the pelvic end. 

nated fimbria, and they give to this portion of the tube the name fimbri- 
ated extremity. It is the " morsus diaboli " of the ancient anatomists. 
The neck of the Fallopian tube marks the union between the ampulla 
and the fimbriated extremity. Distally the canal of the tube terminates 
in the ostium abdominak. Quain cites authority for the statement that 
this orifice is physiologically closed during life, though dilatable to the 
extent of 4 mm., T ^- inch. The expanded mucous-lined portion of the 
tube distad to the ostium abdominale is designated the infundibidum or 
pavilion. The primary fimbriae are four or five in number, but they 
send secondary offshoots from their edges, presenting a complex appear- 
ance. One of the primary fimbriae, larger and less complex than the 



THE FEMALE PELVIC ORGANS. 



49 



others, is attached to the outer extremity of the ovary. It is known as 
the fimbria ovarica. 



Fig. 27. 




Fallopian tube laid open. (After Richard.) 

a, b. Uterine portion of tube, c, d. Plicae of mucous membrane, e. Tubo-ovarian ligaments and 

fringes. /. Ovary, g. Round ligament. 



Fig. 28. 




Fallopian tube ; cross section through ampulla, under low power. (After Luschka.) 
a. Submucous layer, b. Muscular layer, c. Serous coat. d. Mucous membrane, e, e. Vessels. 
1, 1. Small primary folds. 2, 2. Larger longitudinal and accessory folds. 3, 3. Small folds united 
forming canaliculi. 



50 



AXATOMY. 



The mucous lining of the Fallopian tubes is not as closely adherent 
to the muscular structure as is that in the body of the uterus. However, 
it has no distinct subnmcosa. It is disposed in longitudinal folds, 
which are somewhat more complex in the ampulla than in the isthmus. 
This gives to the lumen of the tube on cross section a stellate appear- 
ance. The furrows are continued upon the fimbriae, so that the fimbria 
ovarica presents a gutter leading from the ovary to the pavilion. The 
epithelium is of the columnar variety and ciliated throughout. The cilia 
possess remarkable activity and produce a current toward the uterus. 
The kytadids or cysts of Morgagni are little bodies sometimes found 
attached by pedicles to the fimbriae or to the broad ligaments adjacent 
thereto. They are remnants of foetal structures. 



Fig. 29. 




Uterus, Fallopian tubes, ovaries, and broad ligaments seen from behind. (Browning.) 
a. Fundus of uterus, b. Attachment of utero-sacral ligament, c. Cervix, d. Fimbriated extremity 
of Fallopian tube. e. Ampulla of same. /. Isthmus of same. g. Ovary, h. Line of limitation be- 
tween ovary and broad ligament, i. Ovarian ligament, j. Posterior surface of broad ligament, k. 
Fimbria ovarica. 



The Ovaries. The ovaries are the reproductive glands of the female and 
are the analogues of the testicles in the male. Each is an almond-shaped 
body varying in weight and dimensions according to its functional activ- 
ity. In the adult virgin it may be stated to be 4 cm., 1J inch, in length, 
2 cm., f inch, in breadth, and 1 cm., f inch, in thickness. Its weight 
is 8.5 grammes (J ounce). In the parous woman it is diminished in both 
weight and volume by about 30 per cent. The ovary may be described 
as having two surfaces, two borders, and two extremities. Sections, 
longitudinal and transverse, show it to be irregularly ovoid. One sur- 
face is the flatter, one border the straighter, and one extremity the nar- 
rower. In its migration from the lumbar region, where it is developed, 
the ovary is arrested and drawn between the folds of the broad ligament. 
It may also be considered as pushed into a pouch (the bursa ovarica) 
formed in the posterior layer of the broad ligament. It is thus com- 
pletely invested by peritoneum except along its straighter border. This 



THE FEMALE PELVIC ORGANS. 51 

border, thinner than the other, is designated the hilum. It is here that 
the vessels enter the gland and emerge from it. The ovary, thus invested, 
hangs in the peritoneal cavity from the posterior surface of the broad 
ligament. Its wider extremity is connected to the lateral pelvic wall by 
the ligamentum suspensorium ovarii; its narrower extremity has attached 
to it the ligament of the ovary. 

If the fundus of the uterus be raised and the broad ligaments stretched 
out, the ovaries hang by their attached borders and their more convex 
surfaces are in contact with the ligaments. When, however, the uterus 
is in its usual anteverted position the ovaries are in a plane posterior to 
it. They lie upon the lateral pelvic walls, parallel to and 2.5 cm., 1 
inch, or more below the plane of the inlet. Their narrower extremities 
point forward and inward. Moreover, they may turn upward so that 

Fig. 30. 




72 10 

Sagittal section through the ovary and broad ligament. 
1. Broad ligament. V. Anterior surface. 1". Posterior surface. 2. Mesosalpinx. 5. Fallopian tube. 
6. Round ligament. 7. Ovary. 7' Hilum of ovary with vessels entering the same. 8. Graafian 
follicle. 9. Uterine artery. 10. Uterine veins. 11. Cellular tissue at the base of the broad ligament. 
12. Ureter. (Testut.) 

the flattened surfaces come in contact with the broad ligaments and the 
free borders are superior to the hila. The Fallopian tube curves about 
the distal extremity of the corresponding ovary, and the fimbria ovarica 
is applied to the more convex border. The pavilion falls below the level 
of the ovary, but presents toward it. 1 

Each ovary lies in a fossa bounded above by the external iliac artery 

1 The writer has noticed, while experimenting upon the cadaver, that forcible anteversion of the 
uterus causes the ovaries to turn, so that the surfaces, under other conditions in contact with the 
broad ligaments, are lifted and brought more directly into relation with the fimbriated expansions of 
the Fallopian tubes. 



52 



ANATOMY. 



and below by the ureter. The left may be in contact, internally, with 
the sigmoid flexure of the colon, and the right with a coil of small 
intestine. 

The peritoneal covering of the ovary is so far modified in character as 
to have led some histologists to class it with the mucous rather than with 
the serous membranes. It does not present the glistening appearance of 
peritoneum generally, and minute examination reveals that it is covered 
with epithelial rather than endothelial cells. The cells are of the col- 
umnar variety. They were supposed by Waldeyer to be the parent cells 
of the ova, whence the name u germinal epithelium/ 7 applied to them. 
After puberty the surface of the ovary is uneven, the unevenness being 
occasioned by the presence of unruptured Graafian follicles and of the 
scars of those which have ruptured and discharged their contents. This 
is especially true of the more convex surface. In old age the entire 
surface of the ovary becomes smooth. 

Fig. 31. 




Section of the ovary. (After Schron.) 
1. Outer covering. 1'. Attached border. 2. Central stroma. 3. Peripheral stroma. 4. Bloodvessels. 
5. Graafian follicles in their earliest stage. 6, 7, 8. More advanced follicles. 9. An almost mature 
follicle. 9'. Follicle from which the ovum has escaped. 10. Corpus luteum. 

If a section be made through the gland its stroma will be found to 
consist of a core of loose connective tissue about which are arranged zones 
of connective tissue of varying density. The peripheral zone is dense, 
though thin. It is of a grayish color, which has obtained for it the name 
tunica albuginea ovarii. It is inseparable from the subjacent tissue, and 
is in no sense a distinct envelope. Underlying the tunica albuginea is the 
zona parenchymatosa or cortical zone. This zone may be subdivided into 
two layers. The superficial layer is the denser of the two. In it are 
embedded undeveloped Graafian follicles to the estimated number (for 
each ovary) of thirty thousand or more. The deeper layer of the cor- 
tical zone is less dense than the superficial. It is very vascular and is 
of a reddish color. It is separately designated the zona vasculosa. 

Bands of fibrous tissue radiate from the hilam throughout the stroma 
of the ovary. Into the zona vasculosa unstriped muscular tissue may 
be traced from the broad ligament of the uterus. 

The Graafian Follicle. The Graafian follicle or ovisac as it develops sinks 
into the zona vasculosa, but owing to its becoming more and more dis- 



PLATE VII 



FIG. 1. 




Meso-salpinx laid open, showing the Parovarium or 
Organ of Rosenmuller. (Savage.) 

T, Fallopian Tube ; F, fimbriated extremity of same ; O, ovary ; i, remnant of Wolffian duct ; 
2, 2, remnants of the caecal tubes of the Wolffian bodies ; 3, ovarian ligament. 



FIG. 2. 




Venous Plexuses of the Clitoris, Bulb, Vagina, Bladder 
and Rectum, seen from the side. (Savage.) 

B, bladder partly inflated and with (b) ureter cut; V, vagina ; P, section of pubis; c, clitoris ; 
U, uterus ; R, rectum ; S, sacrum ; /, veins of the bulb ; 2, veins of pars intermedia ; j, efferent veins 
to pubic vein ; 4, dorsal vein of clitoris ; 5, urethral plexus ; 6, vaginal plexus ; 7 to 12, branches 
uniting to form /? the internal iliac vein ; a, pyriformis muscle ; b, great sciatic ligament; c, leva- 
tor ani muscle ; d, coccygeus muscle ; e, suspensory ligament of clitoris ; y, bulbo-vaginal gland ; 
S, g, g, roots of sacral plexus. 



THE FEMALE PELVIC ORGANS. 53 

tended with fluid, at maturity it approaches the surface of the ovary. 
Just prior to its rupture the ovisac presents the following characteristics. 
It is from 1 mm. to 5 mm., ^ to ^ inch, in diameter. It possesses a thin, 
fibrous envelope continuous, apparently, with the stroma of the ovary. 
This envelope sustains bloodvessels and supports a capillary network of 
the same. That part of the envelope projecting upon the surface of the 
ovary is most vascular, and it is here that the future rupture is destined 
to take place. This point is called the stigma. The investing membrane 
of the follicle is lined with several layers of columnar or cuboidal epithe- 
lial cells. This epithelial lining has been named the membrana granulosa. 
At some point, usually opposite the stigma, the cells of the membrana 
granulosa are greatly multiplied, constituting the discus proligerus. In 
the cells of the discus proligerus is embedded the ovum. On pricking 
the follicle a drop of clear serum exudes. At maturity, by the accumu- 
lation of this fluid and the consequent distention of the follicle, the 
investing membrane is ruptured at the stigma and the ovum is discharged 
upon the surface of the ovary. 

The Corpus Luteum. After its rupture the Graafian follicle undergoes 
certain changes resulting in what may be considered a scar. This is 
formed by the infolding of the collapsed cell-wall, and it presents a 
fluted appearance. It is of a yellow color, whence its name, the corpus 
luteum. If the discharged ovum undergoes impregnation the develop- 
ment of the corpus luteum is of longer duration, and results in a larger 
cicatrix than when pregnancy does not occur. 

The Parovarium. Lying between the folds of the mesosalpinx is the 
parovarium, epoophoron, or organ of JRosenmuller. It is a foetal relic and 
functionless, but analogous to the epididymis in the male. It consists of 
a number of convoluted tubules. These converge toward the ovary, to 
the hilum of which they are attached near its distal extremity. They 
spread out, fan-shaped, within the mesosalpinx and open into a duct 
w r hich lies parallel with the Fallopian tube and nearer to it than to the 
ovary. The duct may be continued to the uterus, though its lumen 
becomes closed before it reaches that organ. It may present cystic 
enlargements or cyst-like bodies may be suspended from it by elongated 
pedicles. 

The paroophoron consists of several detached tubules lying internally 
to and below the epoophoron (Quain). It corresponds to the organ of 
Giraldes in the male. (Plate YIL, Fig. 1.) 

The Ligaments of the Ovaries. The ligaments of the ovaries are dense 
fibrous bands about 4 cm., 1J inch, in length, and receiving muscular 
fibres from the external stratum of the uterus. They connect the ovaries 
and the uterus. They are attached to the narrower extremities of the 
ovaries and to the uterus just below and posterior to the attachments of 
the Fallopian tubes. 

The Round Ligaments of the Uterus. The round ligaments of the uterus 
are fibrous bands or cords containing bloodvessels. They pass from the 
uterus, between the folds of the broad ligaments, to and through the 
inguinal canals. They are attached to the uterus just anterior to the 
attachments of the Fallopian tubes. Between the folds of the broad 
ligaments they each receive an investment of muscular tissue from the 
external stratum of the uterus. 



54 ANATOMY. 

In the usual anteverted position of the uterus, the round ligaments 
curve outward, upward, and forward, in front of the ovaries, to reach 
the sides of the pelvis. Here they cross the external iliac arteries. In 
this part of their course they pall forward the anterior layers of the 
broad ligaments, thus appearing to be invested by peritoneum. Leaving 
the broad ligaments they curve forward and inward to the internal 
abdominal rings, through which they enter the inguinal canals. At the 
internal abdominal rings they have the deep epigastric arteries to their 
outer sides. Traversing the inguinal canals they emerge from the exter- 
nal abdominal rings and break up into strands and are lost in the areolar 
tissue of the mons pubis and of the labia majora. 

Though the round ligaments may be well denned throughout their 
entire length, they are, as a rule, difficult of demonstration in the lower 
parts of the inguinal canals, where they frequently consist of fascial 
expansions only. 

In the infant the round ligament is invested throughout with perito- 
neum. This forms a tubular sheath about it, extending well into the 
inguinal canal. It corresponds with the processus vaginalis in the male, 
and is known as the canal of Nuck. As a rule, it is obliterated in the 
adult below the internal ring. However, it not only may persist, but 
may extend beyond the external ring, and into the labium ma jus. 

The entire length of the round ligament is from 10 cm. to 13 cm., 4 
to 5 inches. Its diameter near the uterus is about 4 mm., T 3 g- inch, 
and for the rest of its length a little less. 

The Connective Tissue of the Pelvis. The spaces between the intrapelvic 
structures which have been described are filled in with connective tissue. 
This serves to unite and support the various organs and to sustain the 
vessels which supply them. It is dense and firm at the vesico-vaginal 
and at the recto-vaginal septum. Between the broad ligaments and 
beneath the utero-sacral bands it is reinforced by muscular tissue, as has 
already been described. In other situations, as between the pubic bones 
and the bladder, about the cervix uteri, between the rectum and the 
sacrum, and at the bases of the broad ligaments, it is loose and areolar in 
character. 

Blood- and Nerve-supply of the Pelvic Floor. With the exception of the 
ovarian arteries all vessels supplying blood to the pelvic structures are 
branches of the internal iliac arteries. The anterior trunk of the internal 
iliac artery on each side lies upon the pyriformis muscle. At the lower 
border of this muscle it divides into the sciatic and internal pudic arte- 
ries. Both of these arteries escape from the pelvis through the greater 
sciatic foramen below the pyriformis. The internal pudic artery, wind- 
ing about the ischiatic spine, returns to the pelvis through the lesser 
sciatic foramen and supplies the genitalia. 

The arteries and nerves supplying the genitalia and the pelvic floor in 
the female correspond with those distributed to analogous structures in 
the male. Their distribution has already been sufficiently discussed. 
Attention should be called, however, to the statement of Ranney, that 
the superficial vessels and nerves perforate the deep layer of the superficial 
fascia in the female, though not in the male. The fact should be men- 
tioned, also, that the superficial artery is larger than its analogue in the 
male, and that it is sometimes called the vulvar artery. In this same 



THE FEMALE PELVIC ORGANS. 



55 



connection it should be borne in mind that the anterior layer of the 
triangular ligament is perforated by the vessels which correspond with 
the dorsal arteries and vein of the penis, and with the arteries to the 
corpora cavernosa and to the bulb in the male. 

The vascular and nervous supply of the bladder and of the rectum is 
practically identical in both sexes. 

The Vessels and Nerves of the Vagina. The vagina gets its principal 
blood-supply from the vaginal arteries. These are analogous to the 
inferior vesical in the male. They may arise directly from the parent 
trunks or from the uterine arteries. Reaching the sides of the vagina 
they anastomose with the pudic arteries near the ostium, and with the 
uterine arteries near the cervix uteri. The blood is returned by veins 
which accompany the arteries. First, however, the veins form rich 
plexuses in the vaginal walls both internally and externally to the mus- 
cular coat. (Plate VII. , Fig. 2.) The veins are devoid of valves and 
communicate freely with the pudendal, vesical, and hemorrhoidal plexuses, 
and with the plexuses between the folds of the broad ligament. The 
plexus external to the muscular coat consists of large vessels. These 
veins are surrounded by unstriped muscular fibres. Thus is formed a 
pseudo-erectile tissue. 



TUBAL VESSELS 



Fig. 32. 



ANASTOMOSIS OF 

UTERINE AND 

OVARIAN ARTERIES 




FALLOPIAN 
TUBE 




°I/ARIAN '*& 
'ROUND LIGAMENT 



UTERINE ARTERY 



SUPERIOR VAGINAL 
ARTERIES 



OS UTERI VAGINA CUT OPEN BEHIND 

Bloodvessels of the uterus and its appendages. (Testut.) 

Along the veins of the vagina, and accompanying them, are lymphatic 
canals and spaces. Those of the lower third of the vagina communicate 
with the lymphatics of the vulva, and are drained by the inguinal glands. 
Those of the upper two-thirds join the lymphatics of the cervix and 
empty into a chain of glands which accompany the internal iliac arteries. 

The nerve-supply of the vagina is derived, in the main, from the 
inferior hypogastric plexuses. Branches of the internal pudic nerve are 
distributed to its lower part. 

The Vessels of the Uterus. The uterine artery, upon each side, is given 
off from the anterior trunk of the internal iliac either above the vaginal 



56 ANATOMY. 

or in common with it. It enters the base of the broad ligament and 
descends between the folds to the roof of the vaginal fornix. After 
supplying the cervix it takes an upward turn and reaches the side of the 
uterus at about the level of the os internum. Proceeding upward it 
anastomoses freely at the fundus with the ovarian artery. Throughout 
its course along the body of the uterus it gives off numerous branches 
which, anastomosing with corresponding branches from the opposite side, 
encircle the organ. The parent trunks and their branches, because very 
tortuous in their courses, are spoken of as " the curling arteries of the 
uterus." One branch, larger than the others, at the level of the isthmus, 
is known as the circular artery. It may sometimes be found below the 
level of the isthmus. 

The fundus of the uterus is supplied by terminal branches of the 
ovarian arteries. 

The arteries of the uterus pierce its muscular walls and terminate in 
capillaries within the mucous membrane. 

The veins are large and abundant in the middle muscular stratum. 
Their coats being intimately united to surrounding tissues render them 
always patulous. Rouget describes a direct communication between 
them and the arteries without capillary intervention. This, if true, 
would constitute the uterus an erectile organ. Under the peritoneal 
covering of the uterus the veins form an intricate plexus which commu- 
nicates freely with that in the vaginal walls and with that between the 
folds of each broad ligament. The plexuses thus formed at the sides of 
the fornix have been named the utero-vaginal plexuses. They are of 
especial interest because traversed by the ureters, which, entering the 
pelvis, cross the iliac vessels from without inward and pass under the 
uterine arteries. The ureters here are about 15 mm., |- inch, external 
to the cervix. Having traversed the plexuses above described, they 
curve inward in close contact to the anterior vaginal wall and enter the 
bladder at the lateral angles of the trigone. 

Within the mucous membrane of the uterus are lymph-spaces. About 
the vessels of its muscular walls are perivascular sheaths forming lymph- 
sinuses. Beneath the peritoneal covering is a rich plexus of lymphatic 
vessels. (Plate VIII.) The lymph from the body of the uterus ulti- 
mately reaches the lumbar glands; that from the cervix enters the iliac 
chain. 

The Vessels of the Fallopian Tubes. The ovarian arteries arise from 
the aorta and descend to the lateral pelvic walls. Each enters the 
broad ligament of its own side, and is guided by the ligamentum infun- 
dibulo-pelvicum to the hilum or attached border of the ovary. Along 
this it pursues a tortuous course, and, leaving it, inclines upward and 
inward to reach the cornu of the uterus between the round ligament 
and the Fallopian tube. It gives branches to the ligament, the tube, 
and the ovary, and supplies the fundus of the uterus, anastomosing with 
the uterine artery. The isthmus and the fimbriated extremity of the 
tube are supplied by branches given off directly from the parent trunk. 
The ampulla is, for the most part, supplied by offshoots from the 
branches which are distributed to the ovary. 

The larger subdivisions of the ovarian arteries are accompanied by 
veins. 



PLATE VIII. 







Lymphatics of the Gravid Uterus and Appendages. (Savage.) 



/, 2, superior lumbar glands; j, inferior lumbar glands; ./, sacral glands; 5, external iliac glands; 
6, common iliac glands; 7, ovarian plexus; a, left renal artery; b, left renal vein; c, left ovarian vein; 
d, left ovarian artery; e, aorta; _/", common iliac artery; g. ascending vena cava; //, external iliac artery; 
k, common iliac vein; m, n, ureters; o, right common iliac artery; />, iliacus muscle; s, psoas magnus 
muscle; O, ovary reversed to show lymphatics; K, kidney; T, Fallopian tube. 



PLATE IX. 



Fig. 1. 




Bulb of the Ovary and its Venous Communications. (Savage.) 

O, ovary; T, Fallopiau tube; U, uterus, 
i, uterine vein and plexus; 2, subovarian venus plexus; 3, commencement of ovarian vein. 




Nerves of the Pelvic Organs. (Savage.) 

R, rectum; U, uterus; B, bladder; P. pubis; S, section of the ilium; D, transversus perinei muscle ; 
1, hypogastric plexus; 2, rectal plexus; 3, a lumbar ganglion; 4, 4, ovarian plexus; 5, branch from 
third and fourth sacral nerves. 6, 7, right inferior hypogastric plexus; 8, uterine filaments; 9, vesical 
plexus; io, great sciatic nerve; //, levator ani branch from fourth sacral nerve; 12, pudic nerve; 13, dis- 
tribution of pudic nerve to clitoris. 



THE FE3IALE PELVIC ORGANS. 57 

The arrangement of the bloodvessels, as well as of the lymphatics, in 
the Fallopian tubes is similar to that in the uterus. 

The Vessels of the Ovaries. The branches of the ovarian arteries which 
supply the ovaries are exceedingly tortuous, even to their minute sub- 
divisions. They cover the surfaces of the ovaries and enter them at the 
hila. Those entering the glands form, in the zonse vasculosse, rich capil- 
lary networks about the ovisacs. The veins emerging at the hila enter 
plexuses " in which the ovaries and ovarian ligaments seem to be partly 
embedded" (Savage). (Plate IX., Fig. 1.) To these plexuses is some- 
times applied the name of " the bulbs." Upon each side the blood 
from the bulb, the Fallopian tube, and the body of the uterus enters an 
extensive venous plexus surrounding the ovarian artery. This is the 
pampiniform (tendril-like) plexus, and is drained by the ovarian vein. 

The ovaries are rich in lymphatics. The efferent vessels are joined 
by those from the uterus and by those from the tubes. They form 
plexuses within the folds of the broad ligaments, and the lymph from 
them enters the lumbar glands. 

The Nerves of the Uterus, Tubes, and Ovaries. The uterus is supplied by 
branches from the inferior hypogastric plexuses of nerves, though branches 
from the ovarian plexus as well reach its fundus. The inferior hypo- 
gastric plexuses supply the Fallopian tubes also. The ovaries receive 
their nerve-supply from the ovarian plexus. The method of termina- 
tion of the nerves in the ovaries is undetermined. They have been 
traced into the hilum, where they form a network about the vessels. 
Some investigators claim to have traced them to the Graafian follicles. 

The Inferior Hypogastric Plexuses. The inferior hypogastric are also 
called the pelvic plexuses. (Plate IX., Fig. 2.) They are situated at 
the sides of the rectum, the bladder, and the vagina. In their distribu- 
tion their branches accompany the internal iliac arteries. The plexuses 
are formed by filaments from the hypogastric plexus of the sympathetic 
joined by nerves from the sacral ganglia and branches of the second, 
third, and fourth sacral nerves. The nerves which supply the vagina 
accompany the vaginal arteries. They are derived almost entirely from 
such parts of the inferior hypogastric plexuses as come from the cerebro- 
spinal axis. The nerves which supply the vaginal fornix, the cervix 
uteri, the body of the uterus, and the Fallopian tubes accompany the 
uterine arteries, and upon them may be demonstrated ganglionic enlarge- 
ments. 

The Ovarian Plexus. The ovarian plexus is derived from the renal and 
aortic plexuses of the sympathetic system. It surrounds the ovarian 
arteries, and in its distribution accompanies its branches. 

The Uterus. The uterus is a pyriform body, but it differs in form and 
dimensions in non-parous and in parous women. That of the adult 
virgin when removed from the body weighs between 32 grammes and 42 
grammes, 1 to 1J ounce. Its entire length is about 7.5 cm., 3 inches. 
Xear the centre of its length it presents a constriction, the isthmus. This 
marks the division of the organ into body and cervix. The superior 
portion is the body, and the inferior the neck or cervix. Somewhat less 
than three-fifths of the entire length of the uterus belongs to the body. 
The sagittal diameter at the centre of the body is 2.5 cm., 1 inch, and 
that at the centre of the cervix very little less. The greatest transverse 



58 



AX ATOMY. 



diameter of the body is about 4.5 cm., If inch, and that of the cervix 
2.5 cm., 1 inch. The diameters at the isthmus are somewhat less than 
those of the cervix. The cervical segment is conical in form, and its 
diameters are shortest at its free extremity. The posterior surface of the 
body of the uterus is markedly convex, the lateral surfaces slightly so, 
and the anterior surface almost plane. The superior extremity of the 
tuerus is designated the fundus. It is convex both transversely and 
antero-posteriorly. The lateral angles are known as cornua, and here 
are attached the Fallopian tubes, the round ligaments, and the ligaments 
of the ovaries. The cervix uteri is also slightly convex vertically. This 
is least noticeable over its anterior surface, because the sulcus between 



Fig. 33. 



Fig. 34. 





The uterus of a virgin seen anteriorly. The uterus of a multiparous woman seen anteriorly 

1. The body of the uterus covered with peritoneum. 2. The extravaginal portion of the cervix 

3. The isthmus. 4. The border of the uterus. 5. The intravaginal portion of the cervix. 5'. Th< 

os externum. 6. The posterior wall of the vagina. 7. The uterine extremity of the Fallopian tube 

8. The round ligament. (Testut.) 



the body and the neck is there least marked. The posterior surface is 
rendered more convex by the bevelling off, or thinning out, of the pos- 
terior lip. The free extremity of the cervix presents a small rounded 
opening — the os tincce or external os. After child-bearing this is con- 
verted into a transverse slit. The circumference of the os tincse is 
divided into an anterior and a posterior lip. The anterior is the thicker 
and apparently the more prominent. 

The uterus is a hollow organ. Its walls, however, are in actual con- 
tact. In sagittal section its cavity is seen to extend from the os tincse to 
within 2 cm., f inch, of the free superior surface of the fundus. Its 
most constricted part is at the junction of the body with the cervix. 
Coronal section shows the cavity of the cervix to be fusiform and that 
of the body triangular. The triangular shape of the outline of the bodv 
cavity is less marked, however, in parous women. The constriction 
between the cavities of the cervix and of the body is designated the os 



THE FEMALE PELVIC ORGANS. 



59 



internum. Under normal conditions in the non-gravid uterus it barely 
admits a probe 3 mm., J inch, in diameter. The os internum is situated 
at the inferior angle of the cavity of the body of the uterus. Into the 
lateral angles open the Fallopian tubes. It has already been stated that 
the cervix uteri projects into the upper and anterior part of the vaginal 
vault. The attachment of the vagina to it has led to its division into a 
supravaginal and an infravaginal portion. This attachment of the 
vagina to the cervix is such as to render these portions of about the same 
length anteriorly. Posteriorly, however, the supravaginal portion is 
somewhat the longer. The anterior lip of the cervix is 
apparently the longer of the two. 



, therefore, 



Fig. 35. 





9 11 

Coronal section of the uterus of a nulliparous Coronal section of the uterus of a multiparous 
woman. woman. 

1. Fundus. 2. Lateral walls of the body. 3. Cervix. 4. Isthmus. 5. Cavity of the body. 5'. Inter- 
nal wall of the body. 6. Cornu. 6'. Opening of the Fallopian tube. 7. Arbor vitse. 8. Os internum. 
9. Os externum. 10, W. Lateral fornices. 11. Posterior vaginal wall. (Testut.) 



The cervix of the virgin is conical in shape and is firm to the touch. 
That of the parous woman is longer and more nearly cylindrical, and the 
os tincse is patulous and irregular in outline. 

As a result of childbearing the body of the uterus is somewhat 
enlarged, and the difference between its sagittal and its transverse diam- 
eters is diminished. Its cavity is more capacious and less markedly 
triangular in outline. The whole organ is so changed that the body is 
relatively longer as compared with the cervix. Their lengths now are 
a little more than 2.5 cm., 1 inch, for the cervix, and a little more than 
5 cm., 2 inches, for the body. The weight of the organ is increased by 
about 50 per cent. 

The uterus is essentially a muscular organ. It is lined with mucous 
membrane and partially invested with peritoneum. Its walls are of an 
average thickness of 1 cm., f inch. Though the fibres interlace in 
such a manner as to be inseparable except in the gravid uterus, anatomists 



60 



ANATOMY. 



are almost universally agreed that they are arranged in three distinct 
layers. They are of the unstriated or involuntary variety, and have 
interposed between them connective-tissue cells. The external muscular 
layer or stratum is exceedingly thin, and can be demonstrated upon such 
parts of the uterus only as are covered by the peritoneum, and with this 
it is intimately connected. The fibres of this layer pass from the anterior 
and the posterior surfaces and from the fundus upon the Fallopian tubes, 
the round and the ovarian ligaments, and accompany such parts of the 
peritoneum as form the broad and the utero-sacral ligaments. The 
internal muscular layer is so intimately connected with the mucous mem- 
brane as to be, by some, described with it, for, except in the cervix, there 
exists in the uterus no submucosa. The fibres of this layer have a cir- 
cular arrangement. They are augmented at the orifices of the Fallopian 
tubes, at the os externum, and at the os internum. Those at the os 
internum are considered as forming a sphincter muscle. The middle 
muscular layer constitutes much the greatest part of the structure of the 
uterus, and is continuous with the muscular coat of the vagina. It is of 
an average thickness of 6 mm., \ inch. The fibres have no definite 
arrangement, but interlace in every direction. They develop in size 
enormously during gestation. This stratum is exceedingly vascular. 



Fig. 37. 



Fig. 38. 




External muscular layer of the uterus, seen upon Internal muscular layer of the uterus, seen after 



the anterior surface of the organ. 
1. Tube. 2. Origin of round ligament. 3. Origin 
of ovarian ligament. 4. Transverse fibres. 5. Longi- 
tudinal fibres forming the anterior branch of the 
ensiform fascicle. 6. Fascicle in Z-shape. 7. Ex- 
ternal orifice of the cervix. (Testut.) 



removal of the external and middle layers. 

1. Section of external muscular layer. 2. 
Section of middle muscular layer. 3. Fallo- 
pian tubes. 4, 5, 6. Variously disposed fibres. 
7. Os externum. (Testut.) 



The coats of the vessels are so intimately held to the muscular fibres by 
connective tissue that the veins remain patulous on cross section. 

The walls of the uterus are thickest over the fundus and at the sides 
of the organ. They diminish in thickness at the isthmus and as the 
Fallopian tubes are approached. 



THE FEMALE PELVIC ORGANS. 61 

The cavity of the uterus is liued throughout with mucous membrane. 
This is continuous with that lining the Fallopian tubes, with the ex- 
ternal mucosa of the infra vaginal part of the cervix, and with that 
lining the vagina. It differs in thickness and character in different parts 
of the organ. Its average thickness is 1 mm., -Jg- inch. Over the 
central part of the cavity of the body it is 2 mm., ^ inch, thick, and 
3 mm., | inch, in the cervix. In this latter location, as has already 
been intimated, it is more loosely attached to the underlying structure. 
Contrary to the arrangement in most of the hollow viscera, and probably 
by reason of its firmer attachment to the muscular wall, the mucous 
membrane of the body of the uterus is not thrown into folds or ruga?, 
except, possibly, at the cornua. It is of a dark-red color. That of the 
cervix contrasts decidedly with that of the body. The former is lighter 
in color, is firmer to the touch, and is thrown into plicae or folds. It 
should also be noted that the transition from the mucosa of the body to 
that of the cervix is not gradual but abrupt. The line of demarcation 
is at the os internum. To a peculiar arborescent arrangement of the 
folds of mucous membrane in the cervix uteri has been given the name 
arbor vitas, uterini (plicce palmatce). On the anterior and on the posterior 
walls of this cavity is a median longitudinal ridge from which the plicse 
extend upward and outward. As in the vagina, the markings upon the 
anterior wall are the more distinct, and parturition has the effect of par- 
tially obliterating them upon both walls. It has been claimed by Guyon 
that the ridges upon the one wall are so arranged as to fit into the 
depressions upon the other, thus more completely occluding the cervical 
canal. 

Thickly scattered over the surface of the cavity of the body of the 
uterus are the openings of glands. The glands were originally infold- 
ings of the mucous membrane, but have been developed into distinct 
tubules, frequently descending into the underlying muscular structure. 
They may be simple follicles or have branching extremities. The ducts 
may be straight, or may take a spiral course, but their axes are always 
obliquely inclined to the intra-uterine surface. The walls of the uterine 
glands consist of prismatic or columnar epithelium, supported upon a 
delicate basement membrane. The cells, as well as those of the surface, 
which are also of the same variety, are held together by connective tissue, 
and the connective tissue supports the vessels of the mucous membrane. 
The epithelium of the body of the uterus is provided with cilia. They 
are difficult of demonstration, since they are easily detached and soon 
thereafter lose their characteristic motion. The direction in which they 
propel is downward. 

The mucous membrane of the cervical canal is thicker and firmer than 
that of the body, but is less intimately attached to the subjacent tissue. 
Differences which relate to the circulation will be considered hereafter. 
The presence of papillae, though claimed by Henle, is denied by Klein. 
The glands are of the racemose variety. They are lined by cuboidal, 
non-ciliated epithelium. When their ducts are obstructed the imprisoned 
secretion forms cyst-like bodies upon the surface of the membrane. These 
bodies have been designated the ovula of Naboth. They are pathological 
in character. The surface cells are of the columnar variety to within a 
few lines of the os externum. Here they change, by a dentated border. 



62 



ANATOMY. 



to the variety covering the intravaginal surface of the cervix. The cells 
upon the summits of the plicae are ciliated, while those in the furrows 
are devoid of these processes (Klein). The plica? are absent in the 
lower sixth of the canal. This has led to the erroneous statement that 
the epithelium of the upper part of the cervical canal is ciliated, while 
that of the lower part is not. 

The mucous membrane covering the intravaginal surface of the cervix 
uteri is smooth, closely adherent to the subjacent tissue, and. according to 
Quain, is destitute of glands. It is covered with pavement epithelium. 

Ligaments of the Uterus. The uterus, during its development, may be 
considered as pushing its fundus upward beneath the peritoueal bag, so 
that this membrane partly covers its anterior and its posterior surfaces. 
This extensive serous membrane is reflected from the bladder upon the 
anterior surface of the uterus at about the level of the isthmus. It 
passes upward over the fundus and downward over the posterior wall to 
the vaginal attachment. It is intimately connected with the external 
muscular stratum of the body of the uterus, so much so as to have led 
anatomists to describe the organ as having a peritoneal coat. The ante- 
rior wall of the cervix above the vaginal attachment and below the 
isthmus is connected to the bladder by fibro-cellular tissue. 

The peritoneum covering the uterus extends outward from the whole 
length of each side of the body of that organ to the pelvic wall. The 
attachment to the pelvis is " f rom the great sciatic notch downward 




UTERO-OVARIAN 
VESSELS 



OS UTERI VAGINA 

The uterus and adnexa viewed from the front. (Testut.j 



along the obturator foramen to the level of the spine of the ischium. " 
These two folds of peritoneum, one upon each side, constitute the broad 
ligaments of the uterus. Each ligament consists of two layers of perito- 
neum reinforced by subperitoneal areolar tissue and by muscular fibres 
from the external stratum of the uterus. The broad ligaments together 
with the uterus constitute a partition by which the pelvic cavity is divided 
into an anterior and a posterior recess, the deepest parts of which are the 
vesico-uterine pouch and the cul-de-sac of Douglas, respectively. 



PLATE X 







BREAST OF DARK BRUNETTE, NEAR TERM 
From Life. 



PLATE XI. 



BREAST OF BLONDE IN LATER MONTHS OF PREGNANCY 
From Life. 



THE MAMMARY GLANDS. 05 

The female breasts differ in size and in appearance in different indi- 
viduals. These differences depend upon age, race, condition in life, 
nutrition, and the activity or quiescence of the gland. In the same 
person, the left breast is generally somewhat larger than the right. 

In a well-developed, non- parous white woman the breasts appear as 
hemispherical or conoidal masses, one upon each side. In the negress 
they are pendulous. They are firm to the touch. Each is about 5 cm., 
2 inches, in thickness. The circumference of its base is slightly ellip- 
tical, the major axis being directed upward and outward toward the 
axilla. Internally it overlaps the border of the sternum. Externally 
it is bounded by the mid-axillary line. Vertically it is bounded above 
by the second or third rib, and below by the sixth or seventh rib. Its 
weight averages 175 grammes, or between five and six ounces. 

At the most prominent part of the breast is the nipple or mammilla. 
It usually appears as a conical wart-like excrescence. Sometimes it is 
flattened and ill-defined, or its site may be marked by a depression. 
Surrounding the nipple is a zone of modified integument. It is desig- 
nated the areola. The areola is about 2.5 cm., 1 inch, in width. The 
color of the nipple and of the areola varies with the complexion of the 
individual. In blondes they are a rosy pink ; in brunettes a delicate 
brown. Though the nipple is slightly below the centre of the breast, 
it points upward and outward when the body is in the upright position. 
This is due to the sagging of the base of the gland. The nipple is 
then about opposite the fourth intercostal space. 

The skin of the nipple and of the areola differs from that of the rest 
of the breast and from skin generally. That of the nipple is tough 
and leathery. It is beset with numerous sensitive papillae, is wrinkled 
from the presence within it of unstriped muscular tissue, is supplied 
with large sebaceous glands, is destitute of hairs or of sweat-glands, and 
is perforated near its centre by the openings of the milk-ducts. The skin 
of the areola is delicate in texture. It is abundantly supplied with 
sudoriparous glands. Hair follicles are present. The sebaceous glands 
are markedly developed. They open upon little elevations which give 
to the areola a tuberculated appearance. Near the base of the nipple 
the ducts of a variable number of accessory milk-glauds open upon the 
areola. 

As the first pregnancy advances the breasts increase in size. The 
nipples also enlarge and become cylindrical in shape. The areola? widen 
and undergo deeper pigmentation. The sebaceous glands of the areolae 
become more active. The elevations marking their ducts become more 
prominent. They are now known as the glands of Montgomery. During 
lactation the breast may weigh, according to Testut, as much as 500 
grammes, or over fifteen ounces. 

After lactation the breasts decrease in size, but do not regain their 
former appearance. They lose firmness and become soft and pendu- 
lous. The nipples remain prominent and the areolae wide. In blondes 
the areolae may assume their original color, but in brunettes they remain 
deeply pigmented. 

The mammary gland is made up of from twelve to twenty lobes, each 
of which may be considered a distinct gland. The lobes are pyramidal 
in form, their apices being represented by ducts which discharge at the 



66 



ANATOMY 



nipple. They are encapsulated by a fascia which sends processes between 
them and between the lobules of which they are composed. The cap- 
sule of the mammary gland is concave toward the chest-wall. It is 
attached to the fascia of the underlying muscles by connective-tissue 
bands. These may enclose lymph-spaces, the so-called submammary 
bursce. Occasionally little masses of glandular tissue perforating the 
capsule lie embedded in the pectoral muscle. 

Internally the breasts lie upon the pectoralis major muscles; externally 
and below T they overlap the interdigitations of the serratus magnus with 

Fig. 43. 







Breast of woman who has been pregnant, showing pigmented areola and position of gland. 

(Dennis.) 

the external oblique muscles; externally and above they are separated 
from the serratus magnus muscles by the axillary fascia?. 

The convex surface of the capsule enclosing the lobes is uneven. It 
sends processes to the overlying skin known as the ligaments of Cooper. 

Except beneath the nipple and the areola the superficial fascia of the 
breast contains fat. Fat is also found in the fascia between the lobes. 
Upon the quantity of fat depends in a great measure the size of the breasts. 
Beside the lobes constituting the gland proper, minute glandular bodies 
may be found near the base of the nipple. They are the so-called acces- 
sory glands. They are from five to twelve in number. Their ducts may 



THE MAMMARY GLANDS. 



67 



open independently upon the surface of the areola or may open into the 
principal ducts traversing the nipple. 

The glandular tissue of the breast may be distinguished from the sur- 
rounding fat by its pinkish color and its firmer consistence. Each lobe is 
a compound racemose gland, and consists of a number of lobules. The 
lobules are surrounded and supported by fibrous connective tissue derived 
from the interlobular septa. Each lobule consists of ultimate acini or 
alveoli arranged about a central canal. The canals unite to form the 

Fig. 44. 




RALIS 
NOR 

ICOSTALES 

ATH OF PEC- 

LIS MAJOR 



ISSUE 

L 



SSUE 
L PLANE 
PPLE 



Sagittal section of mamma and chest-wall. (Testut.) 



interlobular ducts. The interlobular ducts unite to form the principal 
duct of the lobe. This is the tubulus lactiferi, or galactophorous duct. 

Before lactation and during subsequent periods of functional inactivity 
the acini are small and undeveloped. They consist of a membrane [mcm- 
brana propria) enclosing a mass of granular polyhedral cells. During 
pregnancy they enlarge, and the central cells soften. At the commence- 
ment of lactation the central cells are discharged as colostrum corpuscles. 
The peripheral cells are of the short columnar variety and line the 
membrana propria. The walls of the ducts are of areolar tissue, in 
which elastic fibres are disposed in both a circular and a longitudinal 



68 



ANATOMY. 



manner. Quain states that there is no muscular tissue in the walls of 
the ducts. This is certainly not true of the larger ducts. Near the 
nipple the tubuli lactiferi show the presence of unstriped muscular fibres 
interlacing and taking courses both circular and longitudinal. The 
latter may be traced for a certain distance into the lobes, and some in- 
vestigators even claim to have discovered stray fibres in the interlobular 
ducts. The epithelium of the ducts varies in different parts of the gland. 
That of the lobular and interlobular ducts resembles the epithelium of 
the acini. That of the main duct is distinctly cylindrical, except very 
near its termination, where it changes to the squamous variety. 

Fig. 45. 




Anatomical arrangement of milk-ducts. 

When formed by the union of the interlobular ducts the tubuli lacti- 
feri converge toward the nipple. Beneath the areola they form sac-like 
dilatations or ampullce. During lactation the ampullae are about 12 mm., 
-J- inch, in length, and 6 mm., J inch, in diameter. They act as reser- 
voirs for the milk secretion during the intervals of suckling. Beyond 
the ampullae the ducts contract in size and lie side by side in the nipple. 
The central ones are somewhat the larger. All open independently of 
one another and by contracted mouths at depressions upon the apex of 
the nipple. 

The arteries of the breast are numerous but small. They do not 
accompany the ducts, but enter at the base of the gland. The inner and 
greater portion of the breast is supplied by the internal mammary artery, 
the anterior or perforating branches of which pierce the intercostal spaces 
to reach it. The anterior intercostal branches of the internal mammary 
artery and the aortic intercostals with which they anastomose, in like 
manner supply the inner portion of the mammary gland. The outer 



THE MAMMARY GLANDS. 



69 



portion gets its blood-supply from the axillary artery through its long 
thoracic and acromio-thoracic branches. To the long thoracic branch of 
the axillary artery is frequently applied the name external mammary. 
An accessory external mammary branch may also be given off from the 
axillary artery and go to the supply of the breast. A rich capillary net- 
work is found upon the outer walls of the acini. 

The blood is returned from the breast through superficial and deep 
veins. The deep veins accompany the arteries for the most part. The 
superficial veins form an anastomosing circle at the base of the nipple 
(eircidus venosus of Haller). They spread over the surface of the breast 
and end in the superior thoracic vein. The superficial veins are espe- 
cially noticeable during lactation. 



Fig. 4C. 




Showing arterial supply of breast. (Testut.) 
A. Mammary gland. B. Pectoralis major muscle. D. External oblique muscle. E, F. Digitations 
of serratus magnus muscle. G. Deltoid muscle. 1. Internal mammary artery. 1', 1". Perforating 
branches of the same. 2. Superior thoracic artery. 2'. Branches of the same. 8. Long thoracic 
artery. 3'. Branches of the same. 4. Superficial vessels of the breast. 5. Perforating branches from 
the aortic intercostal arteries. 6, 7. Axillary artery. 



The nipple is exceedingly vascular, and the vessels are surrounded by 
bundles of unstriped muscular tissue. The contraction of the muscular 
fibres upon stimulation compresses the vessels and causes the so-called 



70 ANATOMY. 

erection of the nipple. It is not to be understood, however, that the 
nipple contains any true erectile tissue. 

The lymphatics of the breast are abundant. They form plexuses in 
the connective tissue about the acini and between the lobules. They 
are found accompanying the smaller vessels and in the sheaths of the 
larger ones. All freely communicate. There are, beside, sac-like dila- 
tations in the skin and fascia, from which cutaneous and subcutaneous 
lymphatics originate. The lymphatics from the inner portion of the 
breast accompany the perforating arteries and empty into the medias- 
tinal glands. Those from the outer portion unite and form three or four 
large trunks. They proceed to the axillary glands. A few canals from 
the vicinity of the nipple empty into a gland situated beneath the outer 
border of the clavicle. 

The nerve-supply to the breast is principally from the intercostal 
nerves through the lateral cutaneous and the anterior terminal branches. 
The descending branches of the superficial cervical plexus also contribute 
cutaneous filaments. The glandular twigs which accompany the ducts 
to the acini have been traced by Eckhard from the fourth, fifth, and 
sixth intercostal nerves. On account of the free communication between 
the spinal nerves and the gangliated cord, sympathetic nerves are con- 
ducted to the mammary gland. " In the nipple many nerves eud in 
tactile corpuscles in the papillae, and some of those in or near the areola 
enter Pacinian corpuscles" (Quain). 

Fig. 47. 



e> 





Lymphatics of breast and axilla. (Cooper.) 

In the periods between lactation the acini collapse, but do not return 
to their former undeveloped condition, and the connective tissue contains 
a greater amount of fat than before the gland became functionally active. 
At the close of the child-bearing period the whole structure undergoes 
atrophy, so that in old age the glandular tissue has practically disap- 
peared. 



PART II. 

PHYSIOLOGY OF PREGNANCY 



CHAPTER II. 

MENSTRUATION.— OVULATION.— DEVELOPMENT OF THE OVUM. 
MENSTRUATION. 

This is the periodica] discharge of blood from the uterus which takes 
place during the whole of genital life — the years included between 
puberty and the climacteric — the period of pregnancy excepted. In 
occasional instances menstruation may also occur during the early months 
of gestation, but after the fifth month, when the decidua reflexa has 
joined the vera and disappeared, the normal source of the discharge is 
completely shut off, and bleeding from the uterus subsequent to this 
time must be due either to a diseased condition of the cervix or to some 
other pathological condition of the uterine tissues. 

Menstruation occurs on the average once in twenty-eight days, but it 
is subject to wide variations in point of time, some women menstruating 
normally at shorter, others at longer, intervals. The duration of the flow 
is usually from three to five days, but it may continue for two or three 
days longer and still remain within normal limits. Every healthy 
woman must be considered a law unto herself in the matter of frequency 
and duration. The source of the flow is the mucous membrane of the 
uterine fundus and body. 

At first the discharge is made up of mucus, epithelia, and some blood ; 
later it consists of nearly pure blood, and finally of a diminishing amount 
of blood, serum, epithelia, granular debris, and some fat. The reaction 
of the discharge is acid from the presence of phosphoric and lactic acids ; 
it is non-coagulable from the admixture of mucus; and it has a peculiar 
penetrating odor due to contained fatty acids. From four to eight 
ounces are lost at each period. 

The function is associated with more or less general and local disturb- 
ance, especially of a secondary or reflex character. 

The primary cause of the flow is to be sought in the ovary, viz., 
in ovulation. The processes affecting the uterus during the menstrual 
act may be considered as taking place in four stages, as follows ; (1) A 
period of construction in which the uterine mucosa becomes tumefied, 
the stroma is infiltrated with serum which often contains blood, the 
vessels are dilated, and the number of epithelial cells lining the glands 
is augmented, while the glands themselves become dilated and filled with 

Op O 

mucus. This condition is probably similar to that which follows impreg- 
nation, the swollen mucous membrane in this instance being called the 
decidua menstrualis. (2) A period of destruction in which the integrity 

(71) 



72 



PHYSIOLOGY OF PREGNANCY. 



of the uterine lining is destroyed, the exposed capillary vessels rupture 
and pour out their blood, which carries with it the products of disin- 
tegration. (3) A period of regeneration in which the swelling and 
hyperemia subside, and the uterine lining is rapidly renewed by the 
proliferation of the stroma cells and the upgrowth of the epithelial cells 
of the glands. This takes place between the sixth and the eighteenth 
day from the beginning of the period (Westphal). These changes are 
followed by (4) a period of quiescence or repose, in which no active 
changes take place in the uterine lining. 

OVULATION. 

This consists in the periodical discharge of the fully ripened ovum 
from the Graafian follicle, and, like menstruation, is probably con- 
fined to the period of genital life. The development of the egg-cell 
from the germinal epithelium is described elsewhere. The young ovum 
is at first surrounded by a single layer of small cells, but by division of 
these a wall several cell-layers deep is finally formed. Between the 
external and the innermost layer a fissure is then developed, the latter 
becoming filled with fluid — the liquor folliculi. The innermost layer of 
cells is thus forced away from the wall, and as the fluid increases a 




9 " So Ei Mp K 

Development of the Graafian follicle (Wiepersheim). 
KE. Germinal epithelium, from which Pfliiger's tubes, PS, in ovarian stroma are developed. So. 
Ovarian stroma, g, g. Small vessels. U, U. Primitive ova. S. Space between membrana granulosa 
and ovum. Lf. Liquor folliculi. D. Discus proligerus. Ei. Ripe ovum, with germ-vessicle and ger- 
minal spot (K). Mp. Membrana pellucida. Tf. Muscular sheath of follicle. Mg. Membrana granulosa. 

vesicle is formed, the cells adhering around the ovum as the discus pro- 
ligerus, which remains attached to the follicle Avail at one point only, 
the farthest from the surface. The wall of the Graafian follicle is com- 
posed of the following layers from within outward : (a) membrana gran- 
ulosa ; (b) the membrana propria, a very thin basement membrane; (c) 



DEVELOPMENT OF THE OVUM. 73 

the tunica propria, which carries the smaller bloodvessels and is com- 
posed of more or less fibrous tissue; and (d) the tunica fibrosa, contain- 
ing much fibrous tissue, aud through which run the larger bloodvessels. 

At one place in the follicle wall (the stigma) no bloodvessels are devel- 
oped, and it is at this point that rupture occurs and permits the escape 
of the ovum surrounded by the discus proligerus, now called the corona 
radiata, and the liquor folliculi. Just before rupture of the follicle cer- 
tain preparatory changes take place, the maturation of the follicle, which 
lead up to the event. The bloodvessels become engorged, the internal 
layer of the wall becomes thickened and is thrown into folds, and the 
liquor folliculi is largely augmented. At this time the Graafian follicle 
projects from the surface of the ovary as a currant-like cyst. 

After the escape of the egg-cell the follicle undergoes certain changes, 
the nature of which is dependent upon the fertilization or otherwise of the 
ovum, the product in either instance being the corpus luteum. When 
fecundation of the ovum does not take place the corpus luteum of men- 
struation, corpus luteum spurium, is formed. The bursting of the follicle 
relieves the pressure on the surrounding bloodvessels, which rupture into 
the cavity, the discharged blood forming a firm clot, the corpus hwmor- 
rhagicun}, which, however, does not become attached to the follicle wall. 
Spindle-shaped connective-tissue cells and large cells containing pigment- 
granules now penetrate the clot, and the follicle wall becomes thickened 
and thrown into folds, thus encroaching more upon the central clot. 
Contraction of the clot follows, and capillary loops surrounded by newly 
formed cells from the follicle wall enter its substance. As these changes 
progress the granules of lutein in the external layer of the clot give rise 
to its yellow appearance. The further changes in the corpus luteum are 
of a retrograde character, the clot and newly formed products gradually 
disappearing, until after eight or nine weeks only a small cicatrix on the 
surface of the ovary remains. It is stated by Dalton that seven or eight 
months may elapse before total obliteration of the follicle takes place. 

In the event of impregnation, the corpus luteum of pregnancy — corpus 
luteum verum — results. Under this condition, instead of diminishing in 
size, the corpus luteum continues to enlarge up to the fourth month, the 
walls becoming thicker and their convolutions more numerous. From the 
fourth to the seventh month a stationary period occurs, but from this 
time on the corpus luteum begins to decline, so that at term it is much 
smaller than at the fourth month. After labor the retrograde changes 
are rapid, and by the eighth or ninth week post partum nearly all traces 
of the corpus have disappeared. 

Although menstruation and ovulation should not be considered as 
necessarily coincident processes, it is altogether probable that the condi- 
tions which influence the one have also an effect upon the other, and 
that, as a rule, the two functions occur simultaneously, and are to a 
greater or less extent interdependent. 

DEVELOPMENT OF THE OVUM. 

Maturation ; Fertilization. The fully developed human ovum is a 
single cell, more or less spherical in form, about 0/2 mm. (yj- inch) in 
diameter, and composed of a yolk, a nucleus, a nucleolus, and two envelop- 
ing membranes. (Fig. 49.) 



74 



PHYSIOLOGY OF PREGNANCY. 



The outermost membrane, Zona radiata or Zona pelhicida, in the 
mature ovum is rather thick and tough, and presents a striated appear- 
ance, owing to the presence of numerous minute pore-canals, through 
which nutrition is supposed to be furnished the ovum. It is derived 
from the secretions of the ovarian tissues. 

The second, or Vitelline membrane, lies in close contact with the yolk 
from which it is developed, and is a very thin and delicate covering. 



Fig. 49. 



GERMINAL 
VESICLE 




CELLS OF 
ORONA. 



ZONA RADIATA. 



NUCLEUS. 
GERMINAL 
SPOT. 
FOOD YOLK, 



Rabbit's ovum (after Waldeyer). 

Between the zona and the second membrane there is a narrow cleft, 
the Perivitelline space, which permits free motion of the ovum within its 
external covering. 

The Yolk or Vitellus is a clear, somewhat granular substance, consisting 
of yolk-grains (food-yolk or deutoplasm), some fat granules, and proto- 
plasm. The latter is usually increased in amount at one point in the 
ovum, around the nucleus, and this part is designated the animal pole, 
while the corresponding opposite point, where the protoplasm is less, is 
known as the vegetative pole. 

The Nucleus of the ovum, also called germinal vesicle or vesicle of 
Purkinje from its discoverer, occupies an eccentric position in the egg- 
cell, and is surrounded by a nuclear membrane. A reticulum or net- 
work of achromatic threads radiates from the nucleolus through the 
interior of the nucleus ; the meshes of this structure are filled with a clear 
fluid, the nuclear sap. 

The Nucleolus, Germinal spot or spot of Wagner, is also placed eccen- 
trically in the nucleus, and is largely composed of chromatin — a sub- 
stance having a marked affinity for staining reagents. 

Maturation of the Ovum. The female cell or ovum, thus briefly de- 
scribed, although fully developed, is still in an unripe condition, unpre- 
pared for the reception of the male fecundating element, and must undergo 
a series of changes, which principally affect the nucleus and nucleolus, 
before fertilization can be accomplished. These changes are known as 
the maturation of the ovum, and take place just before or just after the 
ovum has escaped from the Graafian follicle, occurring without reference 
to the future fate of the egg-cell. 

The first step in the process of maturation is the contraction of the 



DEVELOPMENT OF THE OVUM. 75 

entire yolk. The nucleus then travels toward the animal pole of the 
egg, loses its sap, which becomes mingled with the surrounding proto- 
plasm, and the nuclear membraue shrinks and finally disappears. Achro- 
matic threads then appear in the nucleus in the form of a spindle-shaped 
body, which lies parallel with the surface of the egg, each thread bearing 
a chromatic granule near its middle, which gives rise to the appearance 
of a dark band near the centre of the nuclear spindle. 

A clear space at each end of the spindle then develops threads which 
run to the surrounding yolk substance, the sun-like appearance thus 
produced being termed the Amphiaster. 

The nuclear spindle now assumes an upright position, the chromatin 
granules divide, each half travelling toward its corresponding end of the 
spindle, while the spindle itself surrounded by protoplasm advances to 
the surface of the egg and pushes outward one-half of its entire sub- 
stance into the peri vitelline space. This extruded portion then becomes 
constricted off from the rest of the spindle, and forms the first polar 
globule. (Fig. 50.) 

Fig. 50. 



--fp 



Formation of polar globules in arteria gracialis (after O. Hertwig). 
Sp. Nuclear spindle. Pg. First polar globule. Spg. Second polar globule, fp. Female pronucleus. 

The remnant of the spindle in the egg then a second time undergoes 
the changes just described, and forms in the same manner a second polar 
globule. Three-fourths of the original spindle is thus cast off. The 
remnant of the spindle retires into the egg, disappears temporarily, and 
is then re-formed as the female pronucleus. 

No entirely satisfactory explanation for the formation of the polar 
globules has been advanced; but it is supposed to be effected either to 
lessen the size of the cell nucleus in order to make room for the male 
element, or to prevent self-fertilization, parthenogenesis. 

Fertilization. The ovum, now fully ripe and in condition for fertiliza- 
tion, migrates through the Fallopian tube toward the uterus. The point 
at which the two elements, male and female, meet, is not definitely 
known, but it is supposed to be the outer portion of the tube in the 
majority of instances. 

Recent observations go to show that impregnation may take place any- 
where from the Graafian follicle in the ovary to the cavity of the uterus. 



76 



PHYSIOLOGY OF PREGNANCY. 



Of the whole number of ova which are discharged from the ovary it 
is quite probable that many do not enter the tube at all, but fall into 
the peritoneal cavity and perish. In very rare instances the ovum from 
one ovary is known to have passed entirely around the uterus, and 
entering the tube of the opposite side to have there become fertilized. 

When the spermatozoa and ovum meet, the former penetrate the zona 
radiata, and the first spermatozoon which approaches the vitelline radi- 
ally is met by a slight protrusion of the protoplasm of the egg, which it 
penetrates and, passing inward, enters the yolk. Here the spermatozoon 
loses its tail, and the head, composed largely of chromatin, becomes the 
male pronucleus. 

But one spermatozoon is necessary for fertilizing the ovum, and as 
soon as this has penetrated the yolk a repellent action seems to be set up 
by the latter, whereby other spermatozoa are prevented from passing 
inward. 

After a short resting stage the male and female pronuclei approach 
each other, and, their walls coming in contact, fuse, finally disappear, and 
a single nucleus, somewhat smaller than the original one of the ovum, 
remains as the segmentation nucleus. 

The ovum now enters upon a new stage of development, in which the 
entire egg-cell is broken up into a great number of smaller cells, each 
of which possesses a nucleus. This total division of the ovum is known 
as holoblastic segmentation, the individual cells of which are called blas- 
tomeres. (Fig. 51.) This change first affects the segmentation nucleus 

Fig. 51. 



ZONA 
PELLUCIDA 



POLAR 
GLOBULES 




Diagram showing first stages of segmentation in a mammalian ovum (Allen Thompson, after 

E. van Bekeden). 



which divides by the indirect method (karyokinesis), and forms two 
nuclei. A groove then appears in the axis of the ovum, marked by the 
polar globules, which by continuous deepening completely divides the 
ovum into two cells. A second meridional cleavage plane divides the two 
cells into four, the four are then divided into eight, then into twelve seg- 
ments, and, the process continuing, the ovum is finally converted into 
a mass of cells, which, from its resemblance to the fruit, is called 



DEVELOPMENT OF THE OVUM. 



11 



the Morula or mulberry-body. The process of cell division, although 
described as equal, is not so in fact, for the external cells divide more 
rapidly than the internal, so that there can be differentiated two distinct 
layers, a superficial layer in which the cells are small, and an internal 



Fig. 




Optical section of an oosperm of a rabbit, at two stages closely following upon segmentation (from 
Balfour, after Ed. v. Beneden) : ep, ectoderm ; hy, primary entoderm ; bp, the opening in the ecto- 
derrnic layer at one point, named blastopore by E. van Beneden ; this is not a true blastopore. The 
shading of the ectoderm and entoderm is diagrammatic. 

laver in which they are much larger. At about the time that the morula 
stage is reached a small cavity — the segmentation cavity — makes its 
appearance in the interior of the mass. This is later filled with a clear 
albuminous fluid, which increases rapidly in amount, so that the ovum 



Fig. 53. 




Rabbitt's ovum between seventy and ninety hours after impregnation (after van Benepex'). 

soon becomes distended into a vesicle, the blastodermic vesicle or blast itla. 
(Fig. 52.) On section the blastula is seen to consist of a cavity sur- 
rounded by a single layer of small cells, within which at one point a lens- 
shaped collection of larger cells is attached. (Fig. 53.) 



78 



PHYSIOLOGY OF PREGNANCY. 



With the growth of the blastula the cells of the external layer — 
Raubers's covering layer — become greatly thinned and flattened out, and 
ultimately either disappear or are united to the upper layer of cells of the 
inner cluster. (Fig. 54.) Thus there is at one stage of development an 



Fig. 54. 




Later stages of segmentation in a mammalian ovum (Thomson, after E. van Beneden). 

external thin layer of cells, which extends around the entire surface of 
the blastula, and a second and a third layer which do not so extend at 
this time. 

The covering layer, as stated, disappears, the second layer becomes 
external, the ectoderm, and the third layer, now second, the entoderm. 

Fig. 55. 



A-- 





*^xn> 



Transection of eighteen-hour chick embryo, showing beginning or medullary groove and the three 

layers (Manton collection). 
a. Ectoderm, b. Mesoderm, c. Entoderm. 



From the cells of the two layers thus formed, a third layer — the meso- 
derm — is developed, and grows outward from the median axial line. 
(Fig. 55.) Unlike the other two layers the mesoderm does not at 
first extend entirely around the ovum, but is limited in growth by 
the germinal or embryonic area (Fig. 56), that portion of the egg in 
which the future embryo will be developed. The mesoderm grows in 
all directions, but as it extends cephalad it sends out two projections, 



DEVELOPMENT OF THE OVUM. 



79 



which, leaving 1 a space (the proamnion) just in front of the future head, 
again unite and spread outward. (Figs. 57, 58, 59.) 



Fig. 56. 




Embryonic area of rabbit (after Kolliker). 



At a later period two distinct varieties of cells arise from the meso- 
derm — mesothelium, which possesses the characteristics of endothelium — 
and from this mesenchyme or embryonic connective tissue. 



Fig. 57. 



Fig. 58. 



ap- 



pr- 




~pr 



Diagrams of embryonic area of chick (after Duval). 
ao. Area opaca. ap. Area pellucida, the proamnion in third figure, pr. Primitive streak. 

mcs. Mesoderm. 

From the three primary layers all the parts and tissues of the body are 
developed. 

From the Ectoderm: The skin and its epidermal structures — the mam- 



80 PHYSIOLOGY OF PREGNANCY. 

mary glands, hair, nails, epithelium of the cornea ; the lens of the eye ; 
the cerebrospinal system — the nerves and ganglia ; the optic vesicles and 
nerve; cavity of the mouth, teeth, hypophysis; anus, chorion, amnion, 
placenta. 

From the Mesoderm : The muscles, bones, connective tissue, perito- 
neum, pleura?, pericardium, urogenital apparatus (kidneys, testes, uterus, 
Fallopian tubes, and ovaries), spleen, bloodvessels, blood, lymphatics, 
fat-cells, marrow. 

From the Entoderm : The oesophagus, stomach, intestines, epithelium 
of digestive tract, thyroid and thymus glands, tonsils, lungs, liver, pan- 
creas, bladder. 

Fig. 60. 

Fore-brain. 




Optic vesicles, 

— Mid-brain. 
— Hind-brain. 

- — - Primitive segments. 
— Medullary groove. 

Sinus rbomboidalis. 



Chick embryo. Second day. (Manton collection.) 

At an early stage a linear streak — the primitive streak — (Fig. 66) 
makes its appearance just behind the centre of the embryonic area, and 
runs backward to near the margin of the shield. In front of the primi- 
tive streak the ectoderm thickens into a band of cells several rows deep 
on either side of the median axial line. These thickenings are the medul- 
lary plates. By the upgrowth of the edges of the plates a groove is 
formed — the medullary groove — which by the arching inward and unit- 
ing of the lateral folds is converted into a tube, the medullary or neural 
canal. The formation of the canal begins in the future cervical region 
of the embryo, and progresses most rapidly cephalad ; the posterior por- 
tion, the end of which appears to embrace the beginning of the primi- 
tive streak, remains open for some time, and is known as the sinus 
rhomboidalis. (Fig. 60.) 



DEVELOPMENT OF THE OVUM. 



81 



The neural canal is the proton of the cerebro-spinal system, one-half 
of its entire extent entering into the formation of the brain. Imme- 
diately below the developing neural canal a rod of cells is formed in the 
entoderm, and extends from the future hypophysis to the anterior end of 
the primitive streak. This is the notochord, or chorda dorsalis (Fig. 61, 
6 Cd.), a temporary structure which represents the primitive axial skeleton 
of vertebrates. Developed from the entoderm, the chorda is at first a part 
of that layer, but the latter soon growing under it becomes separated and 
assumes a position directly beneath the neural canal, with which, how- 
ever, it does not unite. 

On either side of the neural groove the mesoderm becomes thickened 
into two longitudinal bands — the muscle plates. That portion of the 
plate nearest the groove is thickest and is known as the segmental zone, 
while the external portion which thins toward the blastodermic wall is 
the parietal zone. 

Fig. 61. 
2Ies « Aid M P b 

\ : ■ i ' Fr 



b= 



Eat 





Fig. 62. 




Fig. 63. 




Fig. 64. 







The segmental zone undergoes transverse cleavage which gives rise to 
a series of cubical bodies — the myotomes (see Figs. 61 to 66). These 
appear first in the neck region of the embryo, and gradually extend 
caudad. The myotomes give rise to most of the voluntary muscles of 

6 



82 



PHYSIOL OGY OF PREGXA NC Y. 



the trunk, and later to those of the extremities, and are indirectly con- 
nected with the formation of the future vertebrae. 



Fig. 65. 




Figs. 61-66.— Development of the neural canal (after Waldeyer). 
Ec. Ectoderm. Ent. Entoderm. Mes. Mesoderm, a, b. Prota of primitive segments (proto vertebrae). 
Md. Medullary groove. Mp. Medullary plate. A. Aorta. Cd. Notochord. X. Wolffian ridge. Wd. 
Wolffian duct. Vc. Cardinal vein. So. Somatopleure. Sp. Splanchnopleure. C. Ccelom. 

Externally to the parietal zone of the muscle plates, the mesoderm splits 
into two layers, an upper or external leaf going with the ectoderm to 
form the somatopleure or primitive body wall, and a lower or internal 
leaf which, with the entoderm, forms the splanchnopleure or primitive 
intestinal wall (see Figs. 61 to 66). The space between these two leaves 
is the ccelom or body cavity (pleuro-peritoneal cavity). 

Folding of of the Embryo. Up to this time the embryo appears to lie 
flat on the blastodermic wall, but now changes arise which tend to carry 
it more and more from its surface position and to force it downward into 
the cavity of the blastula. A groove first appears just in front of the 
cephalic end of the embryo (Plate XII., Fig. 11), the head fold, and later 
one behind, the tail fold, and on either side the lateral folds are formed. 
As the result of the deepening of these folds, the embryo becomes partly 
constricted off from the rest of the blastodermic vesicle. As the folds 
deepen, spaces are shut off at the anterior and at the posterior ends 
of the embryo, immediately below the notochord. These cavities are 
the beginning of the primitive alimentary canal; that in front being 
the fore-gut, and that behind the hind-gut. The middle portion of this 
canal, as it soon comes to be, is still in connection with the yolk-sac or 
umbilical vesicle, by the wide omphalomesenteric or vitelline duct. 
(Plate XII., Figs. 3 to 10.) 

The Foetal Appendages and the Uterine Membranes. As the result of 
the folding off of the embryo, all of the extra-embryonic portion of the 
egg, which constitutes the yolk-sac, becomes partially constricted off as 
a pear-shaped body, which is connected by its smaller end to the primi- 
tive intestinal canal. At a later period the neck of the vesicle becomes 



PLATE XII 




DEVELOPMENT OF THE OVUM. 83 

stretched out into a long thin pedicle, and pedicle and sac are finally 
incorporated in the abdominal stalk during the formation of the umbilical 
cord. The yolk probably supplies for a time partial nourishment to the 
embryo and its appendages. During its passage through the Fallopian 
tube the ovum also derives more or less nourishment from the secretions 
of the parts by which it is surrounded. As development of the embryo 
goes on a larger source of supply is demanded, to which end changes 
take place, bringing the embryo into direct relation with the maternal 
circulation, by which the necessary nourishment for growth and develop- 
ment is obtained. 

At a very early period all of the extra-embryonic somatopleure be- 
comes covered with a growth of delicate villi, which give it a shaggy 
appearance. This is the primitive chorion ; the whole ovum at this time 
is sometimes called the chorionic vesicle. (Fig. 67.) 

Fig. 67. 




Human ovum of second week, showing chorionic tufts, A. Enlarged four times. (Manton collection.) 

At first the villi are composed only of ectodermal cells, but later the 
mesoderm extends into each hollow villus. The whole chorion very 
early develops bloodvessels, but most of these soon become obliterated. 

Coincident with the folding off of the embryo the external walls of 
the folds grow upward and, arching over the back of the embryo, unite 
in the mid-dorsal line. The anterior fold, cephalic cap, probably grows 
more rapidly than the lateral folds, but little is actually known regarding 
this phenomenon from observations on human embryos. The embryo in 
this way becomes inclosed in a thin membranous sac — the amnion. As 
will be seen by reference to Plate V., the amniotic folds are composed 
of two layers, an upper, external leaf — the false amnion — made up of 
ectoderm externally and lined with mesoderm, and a lower or internal 
leaf — the true amnion, which has a layer of mesoderm above and ecto- 
derm below, and hugs the back of the embryo. 



Description of Plate XII. 

Folding off of embryo and formation of amnion and allantois in fowl's egg (after O. Hebtwig). 

a. External germinal layer, mw. Medullary groove. N. Neural canal, of. Amnion fold. vaf. 
Anterior, haf. Posterior, saf. Lateral amniotic folds. A. Amnion, ah. Amniotic cavity. S. Serous 
covering, hn. Umbilicus, sf. Lateral folds, kf 1 , Jcp. Head fold. afb. External, ifb. Internal layers 
of amnion, ur. Border of embryonic area. dr. Intestinal groove, dg. Vitelline duct. al. Allantois. 
ds. Vitellus. dn. Intestinal portion of umbilicus, mk. Middle germinal layer. mk\ Parietal leaf 
of mesoderm, mk-. Visceral leaf of mesoderm, si. Sinus terminalis. dm. Dorsal, vm. Ventral 
mesenterium. Ih. Somatic cavity. lh x . Embryonal portion. ?/;'-. Extra-embryonal portion of somatic 
cavity. Figs. 1, 2, 6, 8, 9, and 10 transections. Figs. 3, 4, 5, 7, and 11 longi-sections of embryo. Figs, 
1, 2, 3, 4, and 5 chick embryo. Fig. 6 fish embryo. Figs. 7 and 11 selachian embryo. 



84 PHYSIOLOGY OF PREGNANCY. 

The interval between the embryo and the true amnion later becomes 
the amniotic cavity. At first the amniotic membrane lies in contact 
with the back of the ernbryo, but soon a clear fluid, the amniotic fluid 
or liquor amnii, is secreted within the sac, and this increasing in amount 
rapidly distends the amnion until some time during the third month this 
membrane comes in contact with the chorion, with which it forms a loose 
attachment. The liquor amnii is a clear, serous fluid, having a specific 
gravity of 1007 to 1028, an alkaline reaction, and a composition includ- 
ing fixed solids, epithelial scales, lanugo, and other matters derived from 

Fig. 68. 



2 / 

> 

( 



■ 








?■ 



I- 




h 



^pn 

m 




P 



1 

Embryo with open membranes. Fifteen to eighteen days. (Coste ) 
1. Allantois (abdominal stalk). 2. Parietal mesoblast. 3. Vitelline membrane, yolk. 4. Amnion. 

5. Heart. 

the embryo or foetus, besides water. It amounts to about one or two pints 
at term, and is probably largely derived by transudation from the mater- 
nal structures. The function of the liquor amnii is manifold: it main- 
tains an equable distention of the uterus, protects the child from external 
violence, and permits of its free movements in utero; it prevents injuri- 
ous pressure on the umbilical cord, and, during labor, softens and lubri- 
cates, as well as assists in the dilatation of, the parturient canal. It is, 
moreover, a source of water-supply to the foetus, bathing its surfaces, 
and being swallowed in considerable quantities. 

By the formation of the amnion the embryo becomes entirely separated 



DEVELOPMENT OF THE OVUM. 



85 



from the chorion except at its caudal end, which remains fixed as the 
abdominal stalk. (Fig. 68.) At an early period a bud-like diverticulum 
— the allantois (see Plate XII., 3 and 4) — develops from the posterior 
ventral end of the hind-gut, and growing outward soon reaches the 
chorion, with which it becomes joined and assists in the formation of 
the placenta. 

The allantois lies beneath the abdominal stalk, and early in its devel- 
opment becomes attached to the lower surface of that part, the two 
together forming the proton of the umbilical cord. 




Semi-diagrammatic outline of an antero-posterior section of the gravid uterus and ovum of five weeks 

(modified from Allen Thomson). 

a. Anterior uterine wall. b. Posterior uterine wall. c. Decidua vera. d. Decidua reflexa. e. De- 

cidua serotina. eh. Chorion with its villi. 



The impulse started by the fecundation of the ovum inaugurates cer- 
tain changes in the uterus preparatory to the reception of the fertilized 
egg, changes which in their earlier stages are probably analogous to those 
taking place at the menstrual period. The whole uterus enlarges, becomes 
more vascular, and its mucosa appears more vascular, spongy, and swol- 
len. At the os internum and the openings of the Fallopian tubes the 
mucous membrane remains thin, so that, as the result of hypertrophy, 
the parts surrounding these apertures are thrown into folds. The entire 
thickened lining of the womb is designated as the decidua vera. (Fig. 69.) 

As soon as the chorionic vesicle enters the uterus, it is usually arrested 
in one of the folds nearest the tube opening, and at once attaches itself 



86 PHYSIOLOGY OF PREGNANCY. 

" by an unknown process of agglutination " (Minot) to the uterine wall. 
The folds by which it is surrounded then grow forward, arch over the 
vesicle, and their edges uniting, it becomes entirely enclosed as within a 
sac. These encompassing folds — the decidua reflexa — as the amnion 
expands are pushed more and more toward the decidua vera, with which 
they ultimately come in contact and unite during the fourth month. 

The reflexa is a temporary structure and disappears by degeneration 
and absorption by the fifth month of pregnancy. 

That part of the uterine mucosa upon which the chorionic vesicle first 
finds lodgement becomes the decidua serotina ; it plays an important role 
in the future vascular arrangements between the mother and child. 

The Placenta and Umbilical Cord. When the chorionic vesicle reaches 
the uterus the tips of the villi penetrate the mucosa, and the embryo is 
at first nourished by osmosis from the maternal structures. The villi of 
the serotinal region, however, increase in size and repeatedly branch, 
and enter later into the formation of the placenta, so that this part has 
been called the chorion frondosum. The remainder of the villi of the 
chorion, called the chorion Iceve, gradually atrophy and disappear some 
time prior to the fourth month. At term the placenta or afterbirth 
(Figs. 70 and 71) is a roundish, oval, or kidney-shaped spongy mass, 
reddish-gray to deep purplish-red in color, with a diameter of six to 
eight inches, and weighs about a pound. It is usually thickest at 
the centre, and gradually thins off toward the edges, which are con- 
tinuous with the amnion and decidua. The placenta consists of three 
essential layers : (1) A maternal zone of decidua, (2) a foetal zone of 
amnion and chorion, and (3) a middle zone in which both the maternal 
and the foetal elements are intimately associated. 

The inner or foetal surface of the placenta, to which the cord is attached 
excentrically, is smooth and glistening in appearance, and is covered by 
the amnion, beneath which the two umbilical arteries and one umbilical 
vein ramify in all directions. The veins are the larger and lie deeper 
and internal to the arteries. The external portion of the placenta pre- 
sents a rough and irregular surface which in the recent state is covered 
with blood and clots. It is broken into asymmetrical patches or 
squares, the cotyledons, between which the decidua serotina dips down 
forming partitions or septa. 

As already pointed out, the caudal end of the embryo is prolonged to 
the wall of the chorionic vesicle as the abdominal stalk. The latter, 
therefore, consists of the same structures as the remainder of the embryo, 
and possesses a rudimentary groove, a somatopleure, and a splanchno- 
pleure. At first the amnion springs from the sides of the stalk. 

By the down growth of the two somatopleural leaves and the uniting 
of their edges on the ventral side of the stalk, a tube is formed, the cavity 
of which is continuous with the cavity of the coelom, and within which 
the allantoic diverticulum and the pedicle of the yolk-sac are imprisoned. 
As a result of the closing in of the tube, which is hereafter known as the 
umbilical cord, the amnion becomes separated from the abdominal stalk, 
the separation beginning at the embryonic end and extending to the 
chorionic attachment. Thus, as has been demonstrated by Minot, the 
umbilical cord is at no time covered by the amnion. The cavity of the 
cord becomes obliterated at an early stage, and the allantois and yolk- 



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DEVELOPMENT OF THE OVUM. 



87 



stalk atrophy and disappear, although it is claimed by some observers 
(Kolliker, Mmot) that the allantois can be distinguished at birth. 

At term the cord has been compared to a " twisted rope of tissues," 
extending from the placenta to the child. The cord is of a glistening 
grayish-white color, of varying thickness, and is usually about 22 inches 
long, but may be either much longer or shorter. 

In structure the cord consists of a covering of epithelium continuous 
with that of the amnion, which surrounds a jelly-like matrix called 
Wharton's jelly. This consists of mucin, branched corpuscles, and em- 
bryonic connective-tissue cells. Within this substance the two arteries 
and one vein run in a spiral course, usually from left to right; it is to 
the fact that the growth in length of the vessels exceeds that of the rest 
of the cord that the twisted appearance of the latter is probably due. 



Fig. 70. 




The internal or foetal surface of the placenta. 



Utero-placental Circulation. The most comprehensive explanation of 
this difficult problem has been advanced by Bumm, whose conclusions 
may be summarized as follows : The decidua gives rise to numerous 
processes between which the chorionic villi penetrate. (Plates XIII. 
and XIV.) The arteries of the processes run in an irregular manner 
with many spiral turns, and as they approach the surface of a process 
become tuft-like, and losing their coats open freely into the intervillous 
spaces. The veins open at the bases of the processes and along the 
decidual margins of the intervillous spaces. The chorionic villi, there- 
fore, hang more or less freely in a blood-filled sinus, Eacli decidual 
process, cotyledon, has its individual circulatory region, the blood pour- 
ing out from the sides of the process and re-entering the maternal circuit 
through the veins at its bottom. 



88 



PHYSIOLOGY OF PREGNANCY. 



The greater the distance from the decidual process, the slower becomes 
the blood-current, until a point is reached where absolute stasis occurs 
with resulting fibrin deposit. The circular sinus at the edge of the 
placenta receives the blood from the lowest processes, but, as it appears 
often interrupted, it can have but limited importance in carrying off the 
blood. The chorionic villi very rarely if ever penetrate into the mouths 
of the arteries, but they do enter the veins and often for a consider- 
able distance. (Plate XIV.) 



Fig. 71. 




?he external or uterine surface of the placenta. 



The Embryonic and Festal Circulation, At a very early period of devel- 
opment the embryonic area presents, on surface view, a netted appearance, 
due to cord-like thickenings in the splanchuopleural mesoderm. Scat- 
tered among these cords are reddish -yellow patches, blood-islands or 
islands of Pander, the cells of which develop haemoglobin, which gives 
rise to their color. This reticulated region is called the area vasculosa, 
and it is bounded by a large vessel, the sinus terminalis. (Fig. 79.) 
By a process of liquid vacuolation the mesodermal cords become hol- 
lowed out, and acquiring a lumen give rise to the primitive bloodvessels. 

An extension of the vascular network takes place by the uniting and 
anastomosing of bud-like offshoots from the primitive vessels, which 
extend toward and finally penetrate the embryo, where they unite with 
the embryonic vessels. 

Coincident with the formation of the extra -embryonic circulation, the 




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CD 

to 

CD 
-*. 


- 




DEVELOPMENT OF THE OVUM. 



89 



embryonic heart is developed and begins 
with the vessels has been established. 



to pulsate before connection 



As the result of splitting of the mesoderm and the folding off of the 
embryo, the splanchnopleural leaves are forced downward, and, approach- 
ing each other, unite in the ventral median line. Before this is accom- 
plished a small cavity makes its appearance in the splanchnic mesoderm 



Fig. 72. 




Schematic representation of the development of the heart (after 0. Hertwig). 
h. Heart, spl. Splanchnopleure. 

of either side in the cephalic region of the embryo. By the down-fold- 
ing of the splanchnopleure these cavities come to lie ventrad to the future 
throat, and are gradually brought together, their walls fusiug. (Figs. 
72 to 74.) These cavities are the proton of the primitive heart, which 
is at the start a double tube. The middle wall of the heart- tube soon 
disappears, a single cavity resulting. The mesodermal cells of the heart 
cavity undergo changes which give rise to the endothelial lining of the 
completed organ. At first the heart is attached to the surrounding 
tissues by a ventral and a dorsal mesocardium, but the former and a 
portion of the latter disappear, leaving the heart projecting freely into 



90 



PHYSIOLOGY OF PREGNANCY. 



the coelomic cavity. The upper end of the heart-tube then dilates into 
what will be the future aortic bulb. 

In the further development of the heart the lengthening of the tube 
in a confined space causes it to assume an S-shaped bend to the right, 



Fig. 



Fig. 76. 




V.h:' 

V.o.m. V.u. V.c. 

Endothelial heart of a human embryo (after His). 
A.b. Bulbus aortse. F.r. Fretum Halleri. V. 
Ventricle. V.h. Auricle. V.o.m. Omphalo-me- 
senteric vein. V.u. Umbilical vein. V.c. Vena 
cava. C.a. Auricular canal. 



Endothelial heart (after His). 
A.b. Bulbus aortae. F.r. Fretum Halleri. V. Ven- 
tricle. P. Wall of pericardium. V.u. Umbilical 
vein. V.o.m. Omphalo-mesenteric vein. V.c.d. 
Cardinal vein. V.j. Jugular vein. V.h. Auricle. 
C.a. Auricular canal. 



that portion to the right and in front representing the future auricles, 
that to the left and behind the ventricles. (Figs. 75 and 76.) 

The auricular portions on either side expand and become somewhat 




Endothelial heart of a human embryo (after His). 
Si-. Sinus venosus. Ho. Auricle. Ca. Auricular canal. VI. Ventricle. 



constricted off from the ventricle, the opening between the two being the 
auricular canal. (Fig. 77.) A partition — the septum superius — then 
develops from above, and growing downward to the auricular canal con- 



DEVELOPMENT OF THE OVUM. 



91 



verts the single auricle into right and left cavities. At a later stage the 
septum is perforated above, giving rise to the foramen ovale, an opening 
between the auricles which persists until some time after birth. The 
separation of the ventricles is first indicated by a groove on the exterior 
of the heart, a septum inferius developing from a corresponding point in 
the interior, and extending nearly upward to the auricular canal, a small 
foramen remaining open. (Fig. 78.) At the same time a division of 
the aortic bulb takes place, the septum extending downward to and 
fusing with the septum inferius. This division of the aortic bulb gives 
rise to two vascular channels, that to the left and in front becoming the 
pulmonary artery, while that to the right and behind is the permanent 
aorta, which has for its opening the interventricular foramen. 



Fig. 78. 



V.C.S. 




Inner surface of heart (after His). 
V.C.S. Superior vena cava. S.S. Septum superius. V.E. Eustachian valve. 
A.E. Auricular canal. S.I. Septum inferius. 



S. Area interposita. 



Coincident with the development of the heart and the extra-embryonic 
circulation, bloodvessels have been forming in various parts of the em- 
bryo, and with the uniting of these vascular channels a primitive circu- 
lation is soon established. 

Primitive Embryonic Circulation. (Fig. 79.) The anterior end of the 
heart prolonged as the truncus arteriosus soon divides in the region of 
the fifth branchial arch into two primitive aorta?, which run forward and 
bend around on either side to the dorsum of the embryo, where they con- 
tinue longitudinally to the caudal end. From the aortas branches are 
given off, the chief of which, the omphalomesenteric arteries, carry most 
of the blood to the capillaries of the vascular area. The return current 
from the sinus terminalis is carried by the anterior and posterior vitelline 
veins, which unite near the middle of the embryo with the omphalo-mcscn- 
teric veins to form a large trunk, the sinus venosus, which enters the 
posterior end of the heart. 

Secondary Embryonic Circulation. Arteries. With the development 
of the allantois and its union with the chorion, further changes in the 



92 



PHYSIOLOGY OF PREGNANCY. 



circulation take place. The posterior portions of the two primitive 
aorta? fuse to form a single permanent dorsal aorta, from which branches, 
the vitelline arteries, are given off to the yolk-sac, and two terminal ves- 
sels — the allantoic arteries — which carry the blood from the placenta to 
the embryo. 



Fig. 79. 
Arc. 



SV. 




Card. 



Om. A. 
Om'. V. 

Diagram of the circulation of a chick at the end of the third day, as seen from the under or ventral 

side (after Minot). 
Bt. Heart. Arc. Aortic arches. Dc. Ductus Cuvieri. Jug. Jugular vein. Ao. Aorta. Card. Car- 
dinal vein. Om.A. Omphalic artery. Om.V. Omphalo-m esaraic vein. ST. Sinus terminahs. SV. 
Sinus venosus. 

The truncus arteriosus also gives off five paired branches — the aortic 
arches — which run right and left around the visceral arches to the primi- 
tive aorta of the corresponding side. (Fig. 80, A.) 

These arches develop from in front backward, and disappear in the 
same order, so that the five pairs are never in a state of perfect develop- 
ment at the same time. By the fourth week changes begin to take place 
in the arches which are indicative of the permanent adult vascular 
arrangement. The internal portions of the first arch on either side 
become the external carotid arteries ; the third arch and the dorsal por- 
tions of the first and second arches give rise to the internal carotid; the 
ventral portions represent the common carotids. 

The left fourth arch enlarges, becoming the permanent aortic arch, 
while the right fourth arch becomes distinctly smaller, loses its connec- 
tion with the aorta, and dividing gives rise to the vertebral artery and its 
branch, the subclavian, of the right side. (Fig. 80, B.) The left fifth 
arch gives off the left pulmonary artery, which at first communicates 
with the dorsal aorta through the ductus a7*teriosus (ductus Botalli). The 
right fifth arch disappears above the origin of the pulmonary artery of 
that side. 



DEVELOPMENT OF THE OVUM. 93 

The iliac arteries arise from the umbilical arteries — the proximal por- 
tions of the allantoic arteries — during the development of the posterior 
extremities. The remainder of the allantoic vessels become the hypo- 
gastric arteries. 



Fig. 80. 



Ao. 



Exc 




Exc 



II in IV 



A. Diagram of pharynx of an amniote vertebrate. B. Diagram of gill arches as preserved in 

mammals (after Minot). 
The shaded portions are those which remain, the unshaded those which disappear. Inc. Internal 
carotid. Ao. Aorta. Ph. Pharynx. Oe. CEsophagus. Hi. Heart. Exc. External carotid. M. Mouth 
invagination. 1, 2, 3, 4, 5. Gill pouches (clefts). I, II, III, IV, V. Aortic arches, da. Ductus arteri- 
osus. P. Pulmonary artery. 

Veins. The blood is returned to the heart by four sets of vessels : 
the jugular, the cardinal, the vitelline, and the umbilical veins. The 
two jugulars receive the blood from the head, the two cardinals from the 
trunk, and both unite to form the ducts of Cuvier, which enter the heart 



Fig. 81. 






Diagramatic figures illustrating the development of the venous system (after O. HertwiuV 
dc. Ductus Cuvieri. je,ji. External and internal jugular veins. S. Subclavian vein. vh. Hepatic 
vein. V. Umbilical vein, ci, ci". Vena cava inferior, ca, cci 1 , ca' 2 , ccfi. Cardinal vein. Ucd. Right and 
left common iliac veins, ad, as. Eight and left brachiocephalic veins, cs. Vena cava superior, cc. 
Coronary vein. az. Azygos vein, hz, hz*. Hemiazygos vein. He. External iliac. Hi. Internal iliac 
r. Renal vein. 



94 PHYSIOLOGY OF PREGNANCY. 

by the sinus venosus. At a later period the right Cuvier's duct becomes 
the superior vena cava ; the left duct disappears. 

The cardinals are in intimate relation with the Wolffian bodies, and 
on the resorption of the latter a middle part of the left cardinal disap- 
pears, its anterior portion becoming the hemiazygos vein. The right car- 
dinal gives rise to the azygos vein, and the posterior portions of both 
cardinals to the internal iliac veins. (Fig. 81.) 

The blood is returned to the yolk-sac by the two vitelline veins, which 
enter the embryo at the umbilicus, run cephalad along the splanchno- 
pleural mesoderm beside the primitive gut, and empty into the sinus 
venosus. 

In the hepatic region the vitellines are united by three transverse 
branches, and, after forming two vascular rings around the duodenal 
portion of the gut, break up into smaller vessels which enter the liver. 
These vessels are afferent, carrying the blood to the liver, where a capil- 
lary network is established; they later become (Fig. 82) branches of the 




Diagram of the liver veins (aftf r His). 
Ts. Stomach. T a'. Right allantoic vein. VI. Ductus venosus or vena Arantii. Vh. Efferent hepatic 
vessel. VI. Afferent hepatic vessel. Vo. Portal vein. Vi. Vitelline vein. W. Liver. Wd. Bile duct. 
Va. Left allantoic vein. Ti. Intestine. Vu. The white vessels represent those which are aborted. 

portal vein. From the capillary network the blood is collected by effer- 
ent vessels which carry it to the heart; these vessels become the hepatic 
veins. At a later period the portal vein is developed from the two 
vascular rings, the right side of the upper ring and the left side of the 
lower ring disappearing, a single vessel remaining, which makes a spiral 
turn around the intestine. 

In the allantoic stalk the two umbilical veins fuse, forming a single 
vessel, which again separates within the embryo and, running in the 
somatopleure to the liver, empties into the duct of Cuvier. After a time 
the right umbilical vein dwindles and breaks up into several branches, 
some of which join the efferent hepatic veins as they leave the liver, 
while the remainder disappear. The left umbilical vein enlarges and 
joins the portal vein just as this vessel enters the liver. 

When the vitelline and umbilical veins lose their direct connection 
with the heart — on account of the intercalation of the hepatic circu- 



PLATE XV. 




Diagramatic Representation of a Human Embryo estimated as 

about Four Weeks old, showing Heart, Blood Vessels, 

Brain and Abdominal Viscera. (Modified from His.) 

Hs, hemispheres; Ast, optic stalk ; Zh, 'tween brain ; Mh, mid-brain ; Js, isthmus of hind-brain ; 
Cb, cerebellum ; Gc. ciliary ganglion ; Rl, olfactory lobe ; Rg, nasal pit ; GO, Gasserian ganglion ; 
Ga, ganglion of auditory nerve; Gh, auditory vesicle ; Gl, ganglion of glossopharyngeal nerve; Gvg, 
ganglion of vagus nerve ; Hp, hypoglossal nerve ; Ci, ganglion of first cervical nerve ; Ok, superior 
maxilla; UK, inferior maxilla; Lg, tongue; KK, larnyx ; Sa, septum atrium; Sv, septum ventricu- 
lorum ; C, internal carotid; Lg, lung; L, liver; St, septum transversum ; Vp, vena portse ; Un, 
Wolffian bodies; Ms, mesentery; Dr, intestine; CI, cloaca; Bl, kidney proton; V, ventricle; Au, 
auricle. 

Trie dorsal aorta and internal carotid arteries are indicated in light red; 
the cardinal and jugular veins are in blue. 



DEVELOPMENT OF THE OVUM. 95 

lation — the liver soon becomes unable to accommodate the increasing 
quantity of blood which passes through it, so that a communicating vessel 
is formed which connects the portal vein, just before it enters the liver, 
with the right hepatic vein just before it terminates in the sinus venosus. 
This is the ductus venosus, and through it the greater quantity of blood 
is carried directly to the heart without having to traverse the liver 
capillaries. 

The vena cava inferior is developed as a small vessel from the ductus 
venosus, and runs through the liver caudad between the kidneys to ter- 
minate in the iliac veins. 

The pulmonary vein at first empties into the left auricle by a single 
opening, but about the fourth month two or three mouths have developed 
and remain permanent. 

The Blood. The primitive red cells are derived from the endothelial 
lining of the vessels and from the blood-islands. According to Minot, 
they are at first spherical, the nucleus is large, and they are surrounded 
by a layer of protoplasm. They multiply by indirect division. Before 
the formation of the lymph-glands little is known regarding the origin 
of the white blood-cells. 

The Embryonic Circulation. In the primitive or vitelline circulation 
the blood is collected from the vascular area by the vitelline or omphalo- 
mesenteric veins, which empty into the sinus venosus. This also receives 
the blood from the systemic veins, and opens into the primitive cardiac 
auricle. From the ventricle the blood passes through the tr uncus arte- 
riosus and the aortic arches to the primitive aorta?, whence it is returned 
through the vitelline or omphalo-mesenteric arteries to the vascular area, 
and to a limited extent to the body of the embryo. 

Following the development of the allantois and the placenta the cir- 
culation becomes more complex. (Plate XV.) 

The blood is carried from the placenta by the single umbilical vein to 
the under surface of the liver, where it divides into two streams, one 
proceeding through the ductus venosus to the inferior vena cava, and 
thence to the right auricle of the heart; the other, being joined by blood 
from the portal vein, passes through the capillaries of the liver, and so 
on through the hepatic veins to the inferior vena cava and the right 
cardiac auricle. From the right auricle the blood is directed by a fold 
— the Eustachian valve — through the foramen ovale to the left auricle. 
Here it meets with the current from the pulmonary veins, and is passed 
through the auricular- ventricular opening into the left ventricle, and 
thence to the aorta and the branches of the systemic vessels. From the 
head and upper extremities the blood is collected by the superior vena 
cava and, passing directly through the right auricle, enters the right 
ventricle, by which it is forced into the pulmonary artery. Just outside 
the lungs, however, the stream divides, a small portion only going to 
these organs, the greater part turning off through the ductus arteriosus 
to the aorta. From the aorta most of the blood passes through the 
hypogastric arteries back to the placenta, a small amount going to the 
lower portion of the embryonic body and extremities. (Plate XVI., A.) 

Changes in Circulation at Birth. By the third or fourth day after birth 
the hypogastric arteries have dwindled and become obliterated; by the 
end of the first week the umbilical vein and the ductus venosus are 



96 



PHYSIOLOGY OF PREGNANCY. 



closed; and by the end of the third week the ductus arteriosus has 
become impervious. The foramen ovale usually closes soon after birth, 
but it may remain patent as a diminutive aperture during the first year, 
or even throughout life. A persistent opening of the foramen results 
in an admixture of the venous and arterial blood in the auricles, which 
gives rise to a general blueness of the surface of the body, a condition 
known in the infant as cyanosis neonatorum, and in the adult as morbus 
ceruleus. 

As the result of the obliteration of the vessels mentioned the blood 
from the cava, superior and inferior, passes from the right auricle to 
the right ventricle, from by the pulmonary artery to the lungs, from 
which it is returned by the pulmonary veius to the left auricle, and so 
on to the left ventricle, by which it is forced into the dorsal aorta and 
distributed to the trunk, head, and extremities. The adult circulation 
is thus established. (Plate XVI., B.) 

The Central Nervous System. Before the closure of the cephalic end 
of the neural canal has taken place, the beginning of the future brain is 
indicated. (Fig. 83.) 

Fig. 83. 

_..-- Fore-brain - - . 




Optic vesicle 




Optic vesicle 



Diagram showing formation of brain (after Bonnet). 
I-III. Primary cerebral vesicles. 



The anterior end of the medullary tube enlarges, and at two points its 
walls become constricted, giving rise to three communicating cavities, the 
primary cerebral vesicles, known as the fore-brain, mid-brain, and hind- 
brain. At about the same time that the cerebral vesicles are forming, 
the cephalic portion of the neural tube becomes bent as the result of the 
unequal growth of the parts. (Fig. 84.) The first of the cerebral 
flexures — the primary head-bend — takes place in the region of the mid- 
brain, the fore-brain being forced ventrad so that it comes to lie at a 
right angle to the mid-brain, the latter being carried forward and 
upward to the top of the head. The second, or neck-bend, occurs at the 
union of the hind-brain and the spinal cord, the whole head being 
thereby thrown further forward and downward, so that the floors of the 
fore- and hind-brains become parallel. The third bend — the varolian 
bend — affects the hind-brain, and consists in a forward growth of this 
vesicle. 

With the beginning expansion of the fore-brain two lateral outgrowths 



fc I 



b3 





X 
< 



DEVELOPMENT OF THE OVUM. 



97 



— the optic vesicles — make their appearance. These soon become par- 
tially constricted off from the fore-brain, their narrow pedicles — the optic 
stalks — being the prota of the optic nerves. The dorsal wall of the fore- 
brain continues to grow forward and upward from the rest of the vesicle, 
and soon forms a fourth ventricle or permanent fore-brain, the proton of 



Fig. 84. 



Mb 



II 



'OP 



>/? 



&p.c 



Brain of human embryo of five weeks, illustrating cerebral flexures (after His). 
H. Hemisphere. Jib. Mid-brain. Hb. Hind-brain. P. Olfactory lobe. OP. Optic nerve. Sp.c. 

Spinal cord. 

the cerebral hemispheres. (Fig. 85.) The original portion of fore-brain 
is now called the inter-brain ; its cavity becomes the third ventricle of 
the adult brain, while the opening between it and the permanent fore- 
brain is the future foramen of Monro. 

The second cerebral vesicle, mid-brain, develops more slowly than the 
other portions of the brain, which soon overgrow it, forcing it down- 
ward and backward. Its walls gradually thicken, while the cavity 
remains practically unchanged as the aqueduct of Sylvius. From the 

Fjg. 85. 




12 3 

Diagram to illustrate the formation of the primitive brain (after Bonnet). 
bo. Olfactory bulb. Vh, Secondary or permanent fore-brain. Zh. Inter-brain. ZL Epiphyses, i, 
Infundibulum. h. Hypophysis. Mh. Mid-brain. Hh. Hind brain. Nh. Medulla or after-brain. pV. 
Pons Varolii, to. Olfactory tract, cs. Corpus striatum, ch. Chorda dorsalis. 1, 2, 3 correspond to the 
tbree primitive cerebral vesicles. 



roof of the mid-brain the corpora quadrigemina are developed, and in 
connection with its floor the crura cerebri. 

The hind-brain, which at the time of the cerebral flexures is the 
longest part of the brain, soon becomes differentiated into two parts, an 
anterior, from the roof of which is developed the cerebellum, and from 
the apex of the floor (varolian bend) the pons Varolii; and a posterior 



98 



PHYSIOLOGY OF PREGNANCY. 



portion, from the thickened floor of which, between the pons and the 
spinal cord, arises the medulla oblongata. The cavity of the hind-brain 
becomes the fourth ventricle of the adult brain. As the result of growth 
and local thickenings the various parts of the brain become differentiated 
from these primary structures. 

The Spinal Cord. The neural canal is at first a simple tube with 
ectodermal walls. (Plate XII., N, Figs. 6, 8, and 9.) In the devel- 
opment of the spinal cord the sides of the tube become thickened, but 
the dorsal and ventral portions remain thin. The central lumen thus 
becomes narrowed. At a late period the sides are differentiated into 
the anterior, lateral, and posterior columns of the cord. The anterior 
median fissure is developed by the forward growth of the ventral por- 
tions of the cord, while the posterior median fissure represents the ob- 
literated posterior end of the central canal. 

Up to the fourth month the cord equals in length the vertebral col- 
umn, and extends from the first cervical to the last caudal vertebra. 
(Plate XVII.) From this time on, however, the bony structures outgrow 
the cord, which appears shortened, and its lower end is drawn out into a 
fine filament — the filum terminate. By the sixth month the cord ex- 
tends only to the sacral canal; at birth it is at the third lumbar vertebra, 
while a year later it is at the first lumbar vertebra, where it remains. 




Transection through the spinal cord of a twenty-two days old sheep embryo (after Bonnet). 



The cord at first consists of gray matter, but with the development of 
the nerve-fibres, the white matter appears as a differentiation of the 
external cell-layer of the cord. 

Two sets of nerve-fibres develop from the cord : motor fibres from the 
nerve-cells of the inner layer, and sensory fibres from the spinal ganglia. 
(Fig. 86.) The most rapid growth in the nerves takes place in the neck 
region, where they arise from the cord at right angles. Lower down, as 
the result of the superior growth of the vertebral column, the nerves 
gradually assume a vertical direction, and remain for some distance 
within the spinal canal before making their exit. The lower bundle of 



PLATE XVII. 



ii 



l IV. 0. V.VI.Vc.VII. 
VIII. 




N.26 



Diagramatie Representation of a Human Embryo estimated as 

Thirty-one Days old, showing Brain, Spinal Cord 

and Nerves. (Modified from His.) 

H, cerebral hemispheres ; Th, thalmencephalon ; MB, mid-brain; Su, sinus precervical is ; H.M, 
hyomandibular cleft (external auditory meatus) ; OF, olfactory pit ; V.b, maxillary branch of fifth nerve 
(trigeminal); Ol, olfactory lobe; Oc, optic cup; Gc, ciliary ganglion; II r, third cranial nerve; IV. 
fourth cranial nerve ; O, ophthalmic branch of fifth nerve ; V, Gasserian ganglion ; Vc, mandibular branch 
of fifth nerve; VII, ganglion of seventh nerve (facial) ; VIII, ganglion of eighth nerve (auditory) : Ay, 
auditory vesicle; IX, ninth nerve (glossopharyngeal) ; X, aranqflion of root of tenth nerve (pneumogas- 
tric) ; XI, roots of eleventh nerve (spinal accessory); XII, roots of twelfth nerve (hypoglossal); FG, 
Froriep's ganglion; N.i, ganglion of first cervical nerve; N.9, gauglion of first thoracic nerve; NM1. 
phrenic nerve ; N. 21, ganglion of first lumbar nerve ; N.26, ganglion of first sacral nerve ; N.31, ganglion 
of first coccygeal nerve ; T, tail ; VI, vitelline loop of intestine ; L, liver ; V, ventricle ; A, auricle. 



DEVELOPMENT OF THE OVUM. 



99 



nerves surrounding the filum terminale thus presents a brush-like appear- 
ance; this has given rise to the name cauda equina. 

Organs of Special Sense. The Eye. The development of the optic 
vesicles as outgrowths of the fore-brain has already been described (see 
Fig. 83). AY hen the vesicles reach the ectoderm a close attachment is 
formed between the two, and the walls of each increase in thickness at 
the point of contact. The ectoderm then becomes invaginated, forming 



Fig. 87. 



PRIMARY^-- 
OPTIC CUP 




SECONDARY 
OPTIC CUP 





Diagrams illustrating the formation of the optic cups and lens. (Kolliker after Remak.) 

Fig. 88. 



K 






v;?. 




- ,.>^ 

Section through the eye of a calf embryo. (After Kolliker.) 



the primary optic cup, the invagination continuing until a vesicle has 
become constricted off the proton of the lens. (Fig. 87.) In front of 
the lens-sac the edges of the ectoderm unite and, together with the meso- 



100 



PHYSIOLOGY OF PREGNANCY. 



derm, which has grown in between the lens and the ectoderm, form the 
proton of the cornea. (Fig. 87.) As the result of the invagination of 
the ectoderm, the wall of the optic vesicle is also pushed inward, forming 
a secondary optic cup, the doubled-in wall of which unites with the pos- 
terior wall of the optic vesicle to form the retina, the posterior layer of 
the wall furnishing the future pigmented layer. 

The space between the retina and the lens develops the vitreous humor, 
while by the splitting of the mesoderm between the lens and the ecto- 
derm the anterior chamber of the eye is formed, and later becomes filled 
with aqueous humor. 

The tissues about the optic vesicle thicken into a capsule which ulti- 



FiG. 89. 




Embryo of second day, showing otic pit (o). (After Kolliker.) 

mately becomes the sclera and the choroid. The opening of the second- 
ary optic cup is filled by the lens, the edges of the cup giving rise to the 
iris, while the central aperture becomes the pupil. 

The doubling in of the optic vesicle extends also to the stalk, along the 
ventral side of which a groove is formed, the choroidal fissure. This 
fissure closes about the seventh week by the fusing of its lips, but before 
this has taken place, an artery — the arteria centralis retinw — has made 
its way along the groove, penetrated the vitreous humor, and sent off 
branches to the lens. The anterior portion of the artery becomes oblit- 
erated during the last month of foetal life. The optic stalk is after a 



DEVELOPMENT OF THE OVUM. 



101 



time converted into a solid rod, which acquires nerve-fibres from both 
the brain and the retina, and becomes the optic nerve. 

Fig. 90. Fig. 91. 



Bee. 





Fig. 90.— Left otocyst of a human embryo of about four weeks. (Minot after W. His, Jr.) 
Rec. Recessus vestibuli. V. Vestibular region. C. Cochlea region. 

Fig. 91.— Left otocyst of a human embryo of about five weeks. (Minot after W. His, Jr.) 
Se. Saccus endolymphaticus. cs. Upper, ci. Lower, chs. Horizontal semicircular canal. Ut. 
Utriculus. Sac. Sacculus. cch. Cochlea. 

Fig. 92. 




KK. 



Section through the labyrinth of ear of sheep embryo. (After Bottcher.) 

El. Recessus labyrinthi : vertical and horizontal canals U. Utriculus. s. Sacculus. 

Or. Canalis reuniens. Dc. Ductus cochlearis. KK. Cartilage. 

The eyelids arise early as upper and lower folds of integument in front 
of the eye. The edges of the lids grow toward each other, meet and 
fuse, but again become separated shortly before birth. 



102 



PHYSIOLOGY OF PREGNANCY. 



The Ear. The development of the ear differs from that of the eye in 
that it is an ectodermal structure entirely separated from the brain. 

Internal Ear. The first indication of the ear appears about the 
fifteenth day as a thickening of the ectoderm just above the first gill-cleft. 
(Fig. 89.) By invagination of this thickened patch a sac is formed, the 
auditory vesicle or otocyst, which grows inward and becomes entirely sepa- 
rated from the ectoderm. At first the otocyst is spherical in form, but 
it soon becomes pear-shaped (Fig. 90) as the result of the development 
of a projection, the recessus labyrinthi, from its dorsal side. By the 
sixth week the otocyst has been converted by a fold into two portions — a 
dorsal part — the utriculus, from which three projections arise, the prota 



Fig. 93. 




Development of external ear. 



(After His.) The figures refer to the auditory tubercles. 
Fig. 94. 





Development of the human external ear. (After His.) 
1. Tragus. 2, 3, c. Helix. 4. Anthelix. 5. Antitragus. 6. Tenia lobularis. 

of the semicircular canals (Fig. 91), and a ventral part, the sacculus, 
from the anterior end of which the cochlea is developed. 

The lower proximal portion of the recessus labyrinthi is also converted 
into two tubes, which open into the sacculus and the utriculus respectively. 
(Fig. 92.) The complicated specialized portions of the internal ear arise 
as differentiations of the ectodermal lining of the structures. 

Middle Ear. The tympanum is developed from the membrane closing 
the first gill-cleft (hyomandibular pouch); the part within giving rise to 
the Eustachian tube and the tympanic cavity, which are lined by entoderm, 
the part without, to the external auditory meatus, being lined by ectoderm. 

External Ear. This is developed from six auditory tubercles which 



DEVELOPMENT OF THE OVUM. 



103 



appear about the external meatus, two from the posterior edge of the 
first branchial arch, one intermediate, and three behind the first gill-cleft. 
(Fig. 93.) The first tubercle becomes the tragus, the second and 
intermediate fuse to form the helix, the fourth gives rise to the anthelix, 
the fifth to the antitragus, and the sixth to the lobe. (Fig. 94.) Very 
little is known regarding the development of the tactile sense; the other 
two organs' of special sense will be described elsewhere. 

The Alimentary Tract. From the three portions of the primitive enteron 
already mentioned are developed the pharynx, oesophagus, stomach, and 
intestines, and in connection with them the lungs, liver, and other tho- 
racic and abdominal organs. 



Fig. 95. 




Embryo of four weeks. (His.) 

1. Cervical spine. 2. Gills (aural opening). 3. Mouth fissure. 4. Nostrils. 5. Amnion. 

6. Chorion and villi. 

The Mouth. In the development of the mesoderm a space, the pro- 
amnion (Fig. 59), is left in front of the head end of the embryo in which 
no mesoderm appears, the ectoderm and entoderm being closely united 
at this point. By the formation of the cephalic fold and the bending of 
the head, this point of union of the two layers, known as the oral plate, 
is carried downward to the ventral side of the head, and comes to lie at 
the anterior end of the fore-gut, occupying all that space between the 
fore-brain and the heart. The forward growth of both the fore-brain 
and the heart gives rise to a depression or pit between them, at the bottom 
of which lies the oral plate. (Plate X II. , Fig. 7, m.) The sides of the 
depression are formed by a layer of somatopleure which extends from 
heart to head, and afterward gives rise to the cheeks. 



104 



PHYSIOLOGY OF PREGNANCY. 



By the rupture of the oral plate a direct communication between the 
pit or oral cavity and the fore-gut is established. 

The Pharynx. The anterior portion of the fore-gut, which from the 
first is the widest part of the primitive enteron, still further dilates at its 
distal end, thus converting the tabular canal into a funnel-shaped cavity, 
the future pharynx. This portion of the primitive gut has no coelomic 
cavity. 

At the beginning of the third week the entoderm of the sides of the 
pharynx develops a series of four paired pouches, the branchial, visceral, 
or gill-clefts (Fig. 95), which grow outward to the ectoderm and unite 
with it. The anterior pair of gill-clefts appear at about the level of the 
mouth, and are followed by the other three pairs in regular order. 
Meanwhile the tissues from the three primary layers along the sides of 



Fig. 96, 




Fig. 96.— Frontal construction of the mouth and pharynx. (After His.) 

Fig. 97.— Frontal construction of the mouth and pharynx, showing development of nose and lungs. 
(After His.) 

the pharynx develop into five ridges between the clefts — the branchial, 
visceral, or gill-arches, which project quite freely from the surface both 
internally and externally. (Figs. 96 and 97.) 

The first visceral, or mandibular, arch, as it is afterward called, forms 
the lower boundary of the mouth, and is developed into the inferior 
maxilla. From this arch a process, called the maxillary process, is given 
off on either side, and these processes uniting at their distal ends form 
the upper boundary of the mouth. The second and third arches give 
rise to the hyoid and thyro-hyoid bones ; the fourth and fifth arches have 
no particular significance, eventually disappearing. 

From the first gill-cleft are developed the Eustachian tube and the 
tympanic cavity ; from the second the tonsils ; while the third and fourth 
clefts are concerned in the formation of the thymus and thyroid glands. 



DEVELOPMENT OF THE OVUM. 



105 



The Nose. At an early stage a thickening of a patch of ectoderm in 
contact with the fore-brain and lying cephalad to the mouth gives rise to 
the olfactory plates. (Fig. 93, Op.) By an upgrowth of the ectoderm 
and mesoderm around the plates they are converted into the nasal pits, 
the lower sides of which remain open as a groove communicating with the 
mouth cavity. A tongue of tissue — the nasal process (Fig. 97, a) — now 
develops from the anterior wall of the head, and as it grows downward 
toward the mouth sends out on either side a rounded protuberance, 
the processus globulari (Fig. 97, b), which unites with the maxillary pro- 
cess. The nasal grooves are thus converted into canals, the posterior 
nasal passages, leading from the pits to the mouth. Later the nasal 
pits become the narrow, slit-like apertures of the anterior nares. The 
alo3 nasi arise from the growth of the lateral margins of the pits. The 
Schneiderian membrane is evolved from the epithelium of the olfactory 

Fig. 99. 




Small in- 
testine 

Vitelline 
duct 



Greater curva- 
ture 



Greater omen- 
tum 



Place ivhere the 
intestines cross 

Large intestine 



Rectum 



Duodenum 




Greater omen- 
tum 

Placewherethe 

intestines cross 



Appendix 
Mesentery 



Vitelline 
duct 



31esocolon 

Large intes- 

tint 

Small intestine 



Rectum 



Diagrams illustrating the development of the stomach, intestine, omentum, and mesentery. 

(After O. Hertwig.) 



plates, and at a later period is brought into relation with the olfactory 
lobes of the brain by means of ganglia which develop from its epithelium. 

The Tongue. The anterior portion of the tongue arises as a small 
tubercle in the median line on the floor of the pharynx, between the ends of 
the first and second arches, the ends of the second and third arches fusing 
to form the proton of the back of the organ. The lingual epithelium is of 
ectodermal origin ; the papillae develop late, and from them the taste-bulbs. 

The oesophagus is that part of the fore-gut lying between the pharynx 
and the stomach. During the fourth week, as the neck elongates the 
oesophagus is rapidly stretched out to a considerable length, but it still 
retains its cylindrical form. 

The stomach appears during the fifth or sixth day as a slight dilatation 
of the primitive enteron between the oesophagus and the liver. (Figs. 
102 and 103.) It soon shifts its position to below the liver. During the 
fifth week it becomes more pyriform in shape, and assumes a transverse 
position in the bodv, its left side coming to the front, while its right side 
is turned backward. During the change in position of the stomach its 
attachment to the dorsal body- wall becomes stretched out as a thin mem- 
brane — the mesogastrium — which, as the stomach rotates, forms a double 



106 



PHYSIOLOGY OF PREGNANCY. 



fold, that part of the membrane along the greater curvature of the 
stomach giving rise to the greater omentum, while that from the smaller 
curvature becomes the lesser omentum. (Figs. 98 and 99.) 

The intestine includes all of the alimentary canal between the stomach 
and the anus. At first it is a straight tube, but as the result of rapid 
growth it soon becomes coiled in order to accommodate its increasing 
length within the abdominal cavity. A duodenal loop (Fig. 100) is 
formed just below the stomach, and lower down a vitelline loop, which 
is in connection with the yolk-sac, appears. The lower portion of the 
intestinal canal enlarges and grows more rapidly than the upper part 
and forms the large intestine. The caecum appears about the fifth week 
as a protrusion from the distal portion of the vitelline loop near the 
yolk-stalk, and from it the vermiform appendix develops as a long and 
slender outgrowth. (Fig. 99.) The posterior end of the intestine 



Fig. 100. 



Fig. 101. 




Posterior Wall 

Dorsal Mesentery 

Pancreas 




Lig. Suspenso rium 
Hepatis 



Fig. 100.— Schematic illustration of the intestinal canal in a human embryo of the sixth week. 

(After Toldt.) 

Fig. 101.— Diagram illustrating the origin of the liver. (After O. Hertwig.) 

sp. QCsophagus. kc. Lesser curvature, ge. Greater curvature, da. Duodenum. d x . Proton of 

small intestine, d-. Proton of large intestine, d 3 . Vitelline duct. mg. Mesogastrium. ms. Mesen- 

terium. m. Spleen, p. Pancreas, cl. Coeliaca. ao. Aorta, met. Mesenterica inferior, ac. Aorta 

caudalis. r. Rectum. 



terminates in a wide dilatation — the cloaca — which forms the common 
receptacle for the excretions from intestines and bladder. 

As the intestine elongates and separates from its attachment to the 
body-wall, the mesoderm is drawn out as a thin membrane, which later 
becomes the mesentery. (Fig. 99.) About the fourth week an invagi- 
nation of the ectoderm takes place on the ventral side of the embryo 
opposite to the terminal portion of the cloaca, by which the ectoderm is 
brought into contact with the entoderm, the two layers giving rise to the 
«n(7//>/ate (Plate X II., Fig. 7, a), and the ultimate rupture of this plate 
forms a cloacal opening which afterward becomes the anus. 

The liver arises about the fifteenth day as a hollow diverticulum from 
the ventral side of the fore-gut just below the heart (Fig. 101), and almost 
immediately gives off a second evagination. (Fig. 102.) The walls of 
these pouches become greatly thickened, and their distal ends are sur- 



DEVELOPMENT OF THE OVUM. 



107 



Fig. 102. 



rounded by a mass of yolk-cells which become separated off from the 
rest of the yolk. A network of solid cords is next developed in the 
cell-mass, and these, acquiring a lumen during the fourth week, form the 
proton of the hepatic ducts. The meshes of the network are filled with 
bloodvessels. The liver enlarges rapidly, so that at birth its weight in 
proportion to that of the whole body is twice as great as in the adult. 
The canal of the original diverticulum becomes the common bile-duct 
(ductus communis choledochus), and from this, before the end of the fifth 
week, a bud is given off to form the gall-bladder. 

The pancreas is developed during the fourth week as a diverticulum 
from the dorsal side of the duodenum nearly opposite the liver evagina- 
tion, and grows into the mesogastrium where it gives off branching buds. 
The duct opening into the intestine at first lies 
in front of the bile-duct, but subsequently runs 
parallel to the latter, and the two open into the 
duodenum by a common orifice. (Fig. 102.) 

During the second week the pulmonary or- 
gans appear as two di verticula from the ventral 
side of the oesophagus just above and behind 
the auricle of the heart, (Figs. 97 and 103.) 
At this point the oesophageal tube is compressed 
laterally, and still further caudad becomes pear- 
shaped, then triangular, and finally separates 
into three divisions or tubes, the posterior tube 
forming the oesophagus proper, and the two 
lateral tubes the bronchi. The slit-like aper- 
ture through which the pulmonary diverticula 
open into the oesophagus just behind the fourth 
branchial arch is the future glottis, while the 
part immediately caudad represents the trachea. 
By the repeated branching of the latter the 
bronchioles and the alveoli appear. 

The larynx arises as a widening of the upper portion of the trachea; 
and the epiglottis is developed from a small tubercle situated posteriorly 
to the tubercle for the tongue. 

The lungs project conspicuously into the body-cavity, and, growing 
dorsad and caudad, push the peritoneum before them in the form of 
pouches which become the pleural sacs. The epithelium lining the pul- 
monary tract is derived from the entoderm, while the spaces between the 
bronchioles are filled with bloodvessels and tissue of mesodermal origin. 

The Urogenital System. The first indication of the urinary organs 
appears about the fifteenth day as a pair of rod-like cell masses, probably 
of ectodermal origin, lying in the tissues, one on either side, between the 
myotomes and the somato-splanchnopleural junction, and extending from 
the region of the heart caudad. Each rod acquires a lumen and becomes 
the Wolffian duct. (Plate XII., Figs. 8, 9, un.) The caudal ends of the 
ducts are at first blind, but by rapid lengthening they soon reach to the 
posterior end of the intestine and open into the cloaca. (Fig. 104.) About 
the eighteenth day a longitudinal ridge appears along the dorsal wall of 
the body-cavity on either side of the basal attachment of the mesentery. 
These ridges project into the body-cavity and constitute the Wolffian bodies. 




Diagram of liver proton. 
(After Gotte.) 
Lung. St. Stomach. I. Liver. 
p. Pancreas. 



108 



PHYSIOLOGY OF PREGNANCY. 



"Within the ridge on the mesenteric side a series of cord-like thickenings 
develop and, acquiring a central canal, grow toward the Wolffian duct 



Fig. 103. 





Diagram showing the development of the lungs. (After His.) 
Fig. 104. 

-Mutter's duct 



Genital gland 



Wolffian body 




Wolffian duct 



Umbilical Artery 



Allantoic stalk 
Uro-genital sinus 



Diagram of urogenital apparatus. (After Bonnet) . 



Fig. 105. 




Rtctum 
1 




1 r^ 






If— Wolffian duct 


ilical opening — ®-^TJ~\\ \ t^s 




\ \ \ fey 




Allantoic stalk — t- \//jlf 


— Kidney proton 


Jr~ 


-Cloaca 



Anal groove 
Diagram of kidney proton and cloacal region. (After Bonnet.) 



DEVELOPMENT OF THE OVUM. 



109 



Fig. 106. 



into which they open as the Wolffian tubules. The distal closed ends of 
the tubules become dilated and then invaginate to form the Malpighian 
bodies ; the glomeruli arise from the branches of the aorta which pene- 
trate the Wolffian body at an early period. The veins, as has been 
mentioned, empty into the cardinal vein. Early in the fourth week an 
evagination appears on the dorsal side of the Wolffian duct just above 
the termination of the latter in the cloaca. (Fig. 105.) The distal end 
of this diverticulum grows rapidly cephalad between the Wolffian body 
and the vertebrae until it reaches the head-end of the former, where it 
dilates and covers the Wolffian body dorsally, forming the proton of 
the kidney. The long canal opening into the Wolffian duct represents 
the future ureter , and its upper 
end, which becomes dilated, the 
renal pelvis. From the dilated part 
of the renal evagination branches 
are given off to form the urinary 
tubules, from the blind ends of 
which the Malpighian bodies arise. 
The kidneys are definitely formed 
by the end of the eighth week, at 
which time the resorption of the 
Wolffian bodies begins, all but the 
cephalic ends of the latter disap- 
pearing. The opening of the ureter 
is subsequently shifted from the 
Wolffian duct to the urogenital 
sinus. (Fig. 106.) 

The suprarenal capsules are de- 
veloped partly from the mesoderm 
and partly from branches arising 
from spinal sympathetic ganglia. 
That part of the allantois con- 
tained within the abdominal cavity 
and lying between the cloaca and 
the umbilicus gives rise during the 
second month to the urinary blad- 
der. The proximal portion of the 
allantois dilates into a spindle- 
shaped vesicle, the upper part of 
which dwindles and finally be- 
comes a cord — the urachus. The 
bladder is lined by entoderm and 
its walls are formed from the meso- 
derm. At the close of the fourth 
week there appears a band of thick- 
ened peritoneum (meso^AeZmm) along 

the external lateral border of each Wolffian body, extending caudad to 
the cloaca. During the fifth week each band acquires a lumen which 
opens above into the body-cavity and below into the cloaca. These are 
the Mullerian duets, the prota of the female internal organs of generation. 

At an early period there appears on either side along the dorsal wall of 




Diagram of urogenital and sexual organs. 
(After Gray.) 
The parts are shown chiefly in profile, but the Mul- 
lerian and Wolffian ducts are seen from the front. 
3. Ureter. 4. Urinary bladder. 5. Urachus. ot. The 
mass of blastema from which ovary or testicle is 
afterward formed. W. Left Wolffian body. x. Part 
at the apex from which the coni vasculosi are 
afterward developed, w, w. Right and left Wolffian 
ducts, m, m. Right and left Mullerian ducts unit- 
ing together and with the Wolffian ducts in grc, the 
genital cord. ug. Sinus urogenitalis. i. Lower 
part of the intestine, cl. Common opening of the 
intestine and urogenital sinus. co. Elevation 
which becomes clitoris or penis. Is. Ridge from 
which the labia majora or scrotum are formed. 



110 



PHYSIOLOGY OF PREGNANCY. 



the coeloin between the Wolffian body and the mesentery a small ridge 
which extends nearly the whole length of the abdominal cavity. (Fig. 
107.) This ridge is the genital fold, and is formed by the thickening of the 
peritoneal epithelium, which at this point is called the germinal epithelium, 
because from it are developed the egg-cells of the female and the sper- 
matozoa of the male. The middle portion of the ridge is the proton of 
the sexual gland — ovary or testis. At a later stage the caudal ends of the 
genital ridge draw toward the median line and unite to form the genital 
cord. The differentiation of the sex, which can be determined micro- 
scopically as early as the fifth week, depends upon the changes which take 
place in the sexual gland. 

In the male the sexual gland becomes the testis. A network of epi- 
thelial cords is first formed, and embedded in these are the primitive 




r~ \iiT~ Cos 



Wolffian body, genital fold, and Mullerian duct of chick embryo, fourth day. (After Waldeyek.) 

Wd. Wolffian duct. Md. Muller's duct. E. Genital epithelium. Ov. Primitive ova. 

Gl. Glomerulus. Ales. Mesentery. C02. Coelom. 

sperm cells. The cords acquire a lumen and become the prota of the 
seminiferous tubules. They connect with the anterior tubules of the 
Wolffian body which grow into the testis during the fourth month, and 
anastomosing in various directions form the rete testis. (Fig. 108, A.) 
The outer tubules of the Wolffian body serve as communicating channels 
with the Wolffian duct — vasa efferentia— the duct itself in its upper por- 
tion becoming the epididymis, and below the vas deferens. In the male 
the middle portion of the Mullerian duct disappears, the upper end in 
contact with the testis giving rise to the hydatid of Morgagni ; its lower 
part buried in the genital cord forms the so-called uterus masculinus. 

In the female the sexual gland becomes the ovary. The sexual cords 
from the genital mesothelium, or, as they are called here, the cords of 



DEVELOPMENT OF THE OVUM. 



Ill 



Ffluger, contain the primitive ova which become surrounded and sepa- 
rated from one another by smaller cells, forming an epithelial boundary 
or follicle around each ovum. The tubules from the Wolffian body grow 
into the ovary in the same manner as into the testis, giving rise to the 
parovarium or organ of Bosenmuller. (Fig. 108, B.) The anterior por- 
tion of the Wolffian duct persists as the longitudinal duct of the paro- 
varium; its caudal end disappears, or remains as the duct of Gartner. 



Fig. 108. 



A. Male. 



B. Female. 



Hydatid 



Yasa efferentia 



Duct of 
epididymis 



Wolffian duct 
(vas deferens) 



Mutter's duct 



Uterus masculinus— 

Genital Cord 




Fimbria 



Parovarium 



■Paradidymis 



Ovary 



Paroophoron 



Mutter's duct 
(Fallopian tube) 

Wolffian duct 
( duct of Gartner) 



Genital cord 




Uterus 



Vagina 



Diagram to illustrate the homologies of the sexual apparatus. (After Minot.) 

The upper portion of the Miillerian duct above the genital cord gives 
rise to the Fallopian tubes or oviducts. At first these tubes run parallel 
with the body, but later they assume an oblique and finally a transverse 
position in the pelvic cavity, as in the adult. The genital folds as the 
result of superior growth of the other parts of the foetus are also carried 
across the body-cavity, and thinning out give rise to the Ugamenta lata 
or broad ligaments. 

The lower portions of the Miillerian ducts included in the genital cord 
fuse in their lower middle portions to form a single tube — the utero- 
vaginal canal, the upper part of which is differentiated during the fourth 
month into the uterine fundus and body, the cervix uteri appearing some 
time during the fifth month. The lower part of the canal dilates and 
becomes the vagina. 

About the fourth week a septum develops and divides the cloaca into 
two cavities, an anterior, the urogenital sinus (Fig. 106), which includes 
the openings of the allantois and the Miillerian ducts, and a posterior, 
anal opening. The further growth of this dividing wall carries the two 
openings more and more apart, and ultimately appears as the perineum. 



112 



PHYSIOLOGY OF PREGNANCY. 



The External Genitals. The development of the external genitalia is 
the same in both sexes up to the ninth or tenth week. About the fifth 
week a small projection — the genital tubercle — is formed by the thicken- 
ing of the anterior portion of the anal plate. This is the proton of the 



Fig. 109. 



Fig. 112. 




|^-LOWER LIMB 




GLANS CLITORIS 
GENITAL RIDGE 
—GENITAL FOLD 
GENITAL FURROW 



Fig. 110. 



Fig. 113. 



MM$ 




-j-GLANS PENIS 
-j-GENITAL RIDGE 
4-GENITAL FURROW 
-{-GENITAL FOLD 
-j-PERINEUM 
ANUS 




CLITORIS 

GENITAL RIDGE 

GENITAL FOLD 
VESTIBULE 
OF VAGINA 
PERINEUM 
ANUS 



Fig. 111. 



Fig. 114. 



L 



GLANS PENIS 
PREPUCE 



GENITAL FOLD 
■GENITAL FURROW 



SCROTUM 



RAPHE OF 
SCROTUM 



,:& 



Six stages in the development of the external genitals. (After Eckee-Ziegler models.) 




PREPUCE 
CLITORIS 
LABIUM MAJUS 



LABIUM MINUS 
VESTIBULE 
OF VAGINA 



clitoro-penis. The tubercle later develops a head or glans, and a furrow 
— the genital groove — appears along its ventral side, running backward 
to the urogenital sinus. During the tenth week a slight elevation — the 
genital labium — arises on either side of the genital tubercle and extends 



DEVELOPMENT OF THE OVUM. 



113 



backward along the lateral margin of the urogenital sinus. Changes 
now take place which differentiate the male from the female organs. 

In the male the genital tubercle elongates and becomes the penis (Figs. 
109 to 111); and the furrow along its under surface is converted into a 
canal — the urethra — by the growth/ apposition, and fusion of the sides of 
the groove. Their line of union is represented in the adult by the raphe 
peni*. Toward the close of the fifth month the prepuce is developed as 
a fold of skin around the base of the glaus. The scrotum arises during 
the fourth month by the meeting and fusion of the genital labia, which 
enlarge and grow downward between the root of the penis and the 
anus. 

In the female the genital eminence remains small and becomes the 
clitoris. (Figs. 112 to 114.) The genital groove is closed in to form the 
urethra, while its side folds develop to form the labia minora or nymphce. 
The genital labia give rise to the labia majora, the anterior extremities 
of which become the mons veneris or mons pubis. 

The Skeleton. The osseous system of the embryo is relatively late in 
appearing, the bones arising either from a preceding cartilaginous stage 
or independently in membrane. The notochord, the earliest indication 
of the axial skeleton, is first surrounded by a membranous sheath, out- 
side of which a cartilaginous tube is subsequently formed, and from this 
arise the bodies and processes of the vertebrae. Ossification takes place 
in each vertebra from three centres, 
one for each arch and one for the body, 
to which two more centres are added 
later for the epiphyses. 

The pelvis appears as a bar of carti- 
lage {ilium) on either side, articulating 
at the middle with the femur, and 
united at their ventral ends by con- 
nective tissue. The ischium and pubis 
arise ventral ly from the acetabular re- 
g : on and uniting at the symphysis en- 
close a space, the obturator foramen. 
By the end of the third month ossifica- 
tion begins from three centres, one for 
each bone, but the union of the three to 
form the innominate bone is not com- 
pleted until puberty. 

The extremities (Fig. 115) arise during the third week as bud-like 
outgrowths from a lateral longitudinal ridge extending along the ventral 
ends of the muscle plates for nearly the whole length of the embryonic 
trunk. 



Fig. 115. 




Development of the human anterior ex- 
tremities. (Allen Thomson, after His.) 
A. At four weeks. B. At five weeks. C. At 
seven weeks. D. At nine or ten weeks. 



114 



PHYSIOLOGY OF PBEGXANCY. 



EMBRYO AND FOETUS AT DIFFERENT PERIODS OF DEVELOPMENT. 1 

First month — visceral arches and clefts readily distinguished. Spinal 
canal closes. Bads of rudimentary extremities appear. Indication of 



Fig. 116. 



Fig. 117. 



Fig. 118. 



Fig. 119. 







Fig. 120. 



Fig. 121. 





Fig. 122. 



Human embryos, first month. X 5. (His.) 

Fig. 123. 





Human embryos, second month. (His.) 

i On account of the great variance of tabulated observations and difference in the development of 
individual embryos of the same age, uniformity and accuracy in weights and lengths are impossible. 
After the second month the weights and lengths given above in grammes and centimetres are taken 
from Hecker's well-known tables. The weights and lengths in grains and inches are from various 
English and American sources. They must be considered as only approximate. 



DEVELOPMENT OF THE OVUM. 



115 



eves, anas, mouth. The heart is four-tenths of an inch long. (Figs. 116 
to 121.) 

Second month — about 2.5 cm., 1 inch long. The eyes, nose and ears 
are distinguishable. Suggestion of hands and feet. External genitals. 
(Figs. 121, 122.) 



Fig. 124. 







ai 





Nine weeks' embryo. Magnified four times. (His.) 



Third month — products of conception about the size of a goose-egg. 
Fingers and toes separated. Nails as fine membranes. Neck separates 
head from body. Sex distinguishable; uterus formed. Length, 4 to 
9 cm., 5 inches; weight, 5 to 20, average 11 grammes, 460 grains. 
(Fig. 124.) 

Fourth month — 10 to 17 cm., 6 inches, long; weight, 10 to 120, 
average 57 grammes, 850 grains. Short hairs, lanugo, present. Head 
equal to about one-fourth of entire body. 

Fifth month— 18 to 27 cm., 10 inches, long; weight, 75 to 500, 
average 284 grammes, 8 ounces. Vemix caseosa forming. Eyelids 
begin to separate. Heart-sounds perceptible. Quickening takes place. 



116 PHYSIOLOGY OF PREGNANCY. 

Sixth month — 28 to 34 cm., 12 inches, long; weight, 375 to 1280, 
average 634 grammes, 23 J ounces. Hair on head. Eyebrows and 
lashes. Testicles near rings. 

Seventh month — 35 to 38 cm., 15 inches, long; weight, 780 to 2250, 
average 1218 grammes, 41 J ounces. Pupillary membrane disappears. 

Eighth month— 39 to 41 cm., 16 inches, long; weight, 1093 to 2438, 
average 1569 grammes, 3} pounds. Left testicle descended. Nails do 
not protrude beyond finger tips. Lanugo begins to disappear. 

Ninth month — 42 to 44 cm., 18 inches, long; weight, 1500 to 2906, 
average 1971 grammes, 4 J to 7 pounds. 

Tenth month — Lanugo almost entirely disappeared. Skin pink; flexor 
surfaces covered with vernix; both testicles descended in males; labia 
majora in apposition in females; intestine contains abundance of 
meconium; eyes open. Length about 50 cm., 20 inches. 



CHAPTEE III. 

CHANGES IN THE MATEENAL ORGANISM CAUSED BY PREGNANCY. 

The fixation of the impregnated ovum in the uterus begins a series 
of changes in the organs and structures immediately concerned in ges- 
tation, and also, though to less extent, in the organism at large. The 
changes which take place in the generative organs, being the most 
important, will first be considered. 

The Uterus, the normal site of pregnancy, is the seat of the principal 
alterations. These changes affect the size, shape, structure, position, and 
properties of the uterus. They begin at conception, and are for the most 
part progressive throughout the entire period of gestation. 

Size. Coincident with the development of the decidua begins a 
gradual growth in the size and weight of the uterus, which continues 
till the later weeks of pregnancy. In the virgin state the uterus meas- 
ures 7 cm., 2} inches, in length, 4.5 era., If inches, in breadth, and 2.5 
cm., 1 inch, in thickness, and weighs about 42.5 grams, one and one-half 
ounces. During the ten lunar months of pregnancy it steadily develops, 
and at the end of that period it is a large, flaccid, vascular organ, measur- 
ing about 35.5 cm., 14 inches, in length, 25 cm., about 10 inches, in 
breadth, 24 cm., about 9 J inches, in thickness, and weighing a kilogram 
or more, two or two and one-half pounds. It has, therefore, increased 
in size some twenty-five times. In capacity it has increased from one 
cubic inch to four hundred cubic inches, and its internal surface is 
expanded from five or six square inches to three hundred and fifty 
square inches. 

Approximate Measurements of the Gravid Uterus at Different 
Periods of Pregnancy. 

Stage of gestation. Total length. Width. 

Twelve weeks 12 cm. 5 inches. 10 cm. 4 inches. 

Sixteen " 15 " 6 12 " 5 

Twenty " 18 " 7 " 15 " 6 

Twenty-four week? . . . . 21.5" 8% " 16.5" 6% " 

Twenty-eight " . . . . 25 " 10 " 18 " 7 

Thirty-two " . . . . 29 " 11% " 20 " 8 

Thirty-six " . . . . 33 " 13 " 23 " 9 

Forty weeks ..... 35.5 " 14 " 25 " 10 " 

Shape. The pyriform shape of the unimpregnated uterus is pre- 
served in the main during the first four or five weeks of pregnancy. 
There is gradually developed, however, some anteflexion, which persists 
for a time longer. During the next few months the lower segment 
expands out of proportion to the growth of the upper segment, and the 
organ thus becomes nearly spherical ; after mid-pregnancy the uterus 
again assumes a pyriform shape. In the intervals of contraction the 
uterus is a simple sac with fluid contents, but under the pressure of the 
abdominal walls it becomes flattened in its antero-posterior diameter, 
the width increasing at the expense of the length. 

(117) 



118 



PHYSIOLOGY OF PREGNANCY. 



Structure. The first effects of pregnancy are to be observed in the 
uterine mucous membrane. The increased vascular supply which attends 
the fixation of the impregnated ovum in the uterus, instead of being 
followed by the ordinary destructive changes incident to menstruation, 
becomes the leading factor in a process of hypertrophy and hyperplasia 
in the mucosa, and results in the formation of the decidua. 

The increase in the bulk of the uterus is mainly due to hypertrophy 
of its structures, and in the later months in some degree to distention. 
During the first two or three months the growth is symmetrical ; later, 
the fundus and body grow more rapidly than the cervix. First occur 
a thickening and softening of the mucous membrane, which also becomes 
more vascular. Similar changes take place in the parenchyma of the 
organ, owing to hyperplasia of the muscular and connective-tissue ele- 
ments, and of an increase in the number and size of the bloodvessels, 
lymphatics, and nerves. In the later months of pregnancy the walls 
become thinner, till at term they measure from one-sixth to one-fourth 
of an inch in thickness. This thinning of the uterine walls is the result 
of stretching, from the distention of the organ by its growing contents. 
The growth of the uterus in the later months of pregnancy is largely by 
dilatation. 

During gestation the non-striated muscular fibres which make up the 
bulk of the uterine walls are enormously developed, some of them becom- 
ing eleven times longer and five times broader than in the unimpregnated 
state. (Fig. 125.) In advanced pregnancy three muscular layers are easily 



Fig. 125. 



Fig. 126. 





Muscular fibres of uterus 
during gestation. (Wagner.) 



External muscular coat, anterior aspect. 
(Deville.) 



differentiated. The external layer is thin, and intimately adherent to the 
peritoneum, sending out bundles to the tubes and to the broad and round 
ligaments. (Fig. 126.) The middle layer forms the bulk of the uterine 
walls, and is composed of circular fibres surrounding the vessels and of 
longitudinal fibres interlacing with one another. (Fig. 127.) The inner 



CHANGES IN THE MATERNAL ORGANISM. 



119 



layer, also thin, is composed mainly of circular fibres concentrically 
arranged around the os internum and the orifices of the tubes. (Fig. 
128.) Clinical evidence indicates the existence of a sphincter muscle 
at the os internum; but anatomists are not yet decided upon this point. 



Fig. 127. 




Fig. 128. 



Middle muscular coat at fundus, where the placenta was seated. The crossing fibres form rings 

around the vessels which constrict them. (Henle.) 

a, a, superficial layer dissected back; b, bundles belonging to the inner layers ; t, t, tubes. 

The uterine wall, instead of being hard and firm to the sense of touch, 
as in the non-pregnant state, becomes so soft and elastic that the foetal 
parts can be felt through it. 

The arteries become larger and longer and more tortuous ; in places 
they empty directly into the veins. 

The veins dilate into large channels called sinuses. So closely united 
are they with the surrounding connective tissue that when cut they do 
not collapse. The sinuses are largest 
within the placental area. 

The lymphatics participate in the 
general hypertrophy and hyperplasia 
of the uterine structures ; starting 
from the deeper portion of the mucous 
membrane they traverse the muscu- 
lar layers, and are gathered together 
in extensive subperitoneal plexuses, 
which are developed most abun- 
dantly over the fundus and sides of 
the uterus. 

The nerves likewise increase in 
length and thickness, and grow in- 
ward toward the uterine cavity. 
The cervical ganglion is more than 
doubled in size, and smaller ganglia 
may be observed on the inner surface 
of the uterus. 

The peritoneal covering of the 
uterus grows by formation of new 
tissue-elements as the uterus develops. 
It has only a loose attachment to the 
lower segment of the womb. 

Position. At the same time with the changes already mentioned 




Internal muscular layer. (Devilled 
a, section of anterior uterine wall : b. tri- 
angular bundle: c, iibres running' to the 
tubes ; d, d, orifices of tubes : e, e, transverse 
fibres ; v, vagina. 



120 



PHYSIOLOGY OF PREGNANCY. 



Fig. 129. 



there appear marked alterations in the position of the uterus, varying 
from time to time as pregnancy advances. During the first and second 
months the increasing size and weight of the organ cause it to assume a 
somewhat lower position in the pelvic cavity, with but little alteration 
of the normal axis. But during the third month a still greater increase 
in size and weight, in conjunction with the force of gravity acting upon 
the upper end of the uterine lever, causes the fundus to fall forward, and 
a corresponding rise of the cervix to take place. There is an increase 
in the normal anteversion of the uterus. 

Since, during the first three months of pregnancy the enlargement is 
principally in the antero-posterior and lateral diameters, the uterus 
remains within the true pelvis, the fundus not rising above the symphysis 
pubis. In the early part of the fourth month the longitudinal increase 
becomes apparent, and the growing uterus can no longer be accommo- 
dated within its former boundaries ; it begins to rise above the pelvic 
brim ; at the fifth month it fills the hypogastrium, and at the sixth it 
reaches to the level of the umbilicus. 

At about eight and one-half months the fundus is nearly in contact 
with the ensiform cartilage. (Fig. 129.) Within the last two weeks 

of pregnancy the uterus sinks more 
deeply in the true pelvis, and assumes 
a lower position than before, the fundus 
resting downward and forward from 7 
to 8 cm., 2f to 3^ inches, below the 
ensiform cartilage. This sinking of the 
uterus is termed lightening. In pri- 
miparse the descent of the pregnant 
uterus within the true pelvis is more 
noticeable, because of the greater ri- 
gidity of the abdominal walls. The 
descent of the foetal head into the pel- 
vic brim during the last weeks of 
utero-gestation affords satisfactory evi- 
dence that the pelvic inlet is relatively 
ample. 

The position of the uterus is influ- 
enced also by the posture of the woman. 
When she stands, the body of the 
uterus is supported by the anterior 
abdominal wall ; when she is in the 
recumbent posture, it rests against the 
vertebral column, with the fundus approaching the diaphragm ; when 
in a lateral posture, it gravitates to the dependent side. 

After the body of the uterus has risen out of the lower pelvis its axis 
is generally inclined to the right, and the uterus is rotated somewhat to 
the right, its anterior surface looking toward that side. 

Properties. The foregoing changes in the uterus imply the assump- 
tion of new and unusual properties. The muscular walls, with their 
enormously hypertrophied fibres, are yielding and elastic. This elas- 
ticity permits of the movements of the foetal body common to this 
period of gestation. The uterus gradually acquires an increased irrita- 




Size of uterus at various periods of 
pregnancy. 



CHANGES IN THE MATERNAL ORGANISM. 121 

bility, and responds more readily to stimulation of its muscular fibres. 
Growing contractility causes the physiological phenomena of painless 
and painful contractions common during the later weeks of pregnancy. 

The Cervix. Many varying opinions exist as to the part played by 
the cervix in the general uterine enlargement. Discussion in this place 
is unnecessary ; it is sufficient to say that the weight of evidence favors 
the belief that the cervix has a limited share in the formation of the 
fully developed body of the pregnant organ. As previously stated, 
during the first three months of pregnancy the growth is about equal 
in all parts of the uterus, the cervix reaching a length of little more 
than 5 cm., 2 inches. The assumed shortening of the cervix during 
the later weeks of pregnancy is only apparent. The actual length of 
the cervix remains undiminished till the onset of labor. 

The hyperemia which attends the development of the cervix occa- 
sions a physiological softening of the tissues, manifested first in those 
portions of the cervix in which the least resistance is encountered, 
viz., under the mucous membrane at the os externum, and extending 
thence from below upward toward the os internum, the progress of the 
softening being relatively more rapid toward the end of pregnancy. 
The follicles of the cervical mucous membrane furnish an abundant 
supply of thickened secretion, filling the canal and forming what is 
called the "mucous plug." The orifices of the mucous follicles fre- 
quently become occluded. The sacs then become distended with their 
own secretion, and project from the surface of the mucous membrane, 
forming the Nabothian ovules. The cavity of the cervix is dilated 
and funnel-shaped, admitting the finger-tip to or through the internal 
os in the last month. 

During the later weeks of gestation the cervix measures 4 cm. (from 
1^ to 1§ inches). Immediately before labor the vaginal portion of the 
cervix projects less and less into the vagina ; the apparent shortening 
being due to the swelling of the vaginal walls and of the tissues at the 
junction of the cervix and vagina, and to the traction exerted by the 
longitudinal and diverging muscular fibres of the corpus uteri. In 
primi parse the changes in the cervix begin at an earlier period, owing 
to the greater resistance of the tissues of the uterine body. 

The Adnexa. The folds of the broad ligament gradually become sepa- 
rated, and at the end of pregnancy the ovaries and Fallopian tubes are in 
close contact with the uterus, the ovaries assuming a vertical position 
above the pelvic brim, the left ovary being accessible at times on palpa- 
tion. The tubes are vertical. The thickened round ligaments may be 
detected during a contraction ; the location of their upper ends gives a 
clue to the seat of the placenta. If these cords run from the middle of 
Poupart's ligament halfway up the uterus, a high position of the placenta 
is determined. Conversely, ligaments reaching high on the ovoid point 
to a lower placental insertion. Round ligaments converging on the ante- 
rior face indicate posterior implantation, while convergence behind gives 
warning that the incision for Csesarean section will start a vigorous 
hemorrhage as the operator opens the anterior uterine wall. 

The Pelvic Peritoneum, in its relation and disposal, undergoes marked 
changes, in regard to which there is not entire unanimity of opinion. 
It is obvious that the peritoneum on each side of the uterus must be 



122 PHYSIOLOGY OF PREGNANCY. 

elevated to a considerable extent during pregnancy, but with refer- 
ence to the peritoneum covering the anterior and posterior fossa? — the 
vesico-uterine cul-de-sac and that of Douglas — there is some differ- 
ence of opinion. Polk holds that these, too, are raised by the mechan- 
ical action of the uterus during its growth, which at the same time strips 
the peritoneum from the bladder. On the other hand, the observations 
of Webster on frozen sections seem to prove that the floors of the two 
fossa? mentioned are as low during pregnancy as in the nulliparous state. 
According to the latter author, the bladder is stripped of its peritoneum 
by the sinking of the pelvic floor. 

The Vagina partakes of the increased nutritive activity of pregnancy. 
Growing vascularity causes thickening and softening of the mucous 
membrane, which furnishes a more abundant secretion. The enlarged 
vessels of the venous plexus impart a bluish or violet color to the 
vagina. The vagina is increased in length, and though it is drawn 
upward by the uterus during pregnancy, the columns of the anterior 
wall frequently protrude from the vulva. The swollen papilla? cause 
the mucous membrane to present a granular feel to the examining 
finger. 

The External Genitals share in these changes. The largely devel- 
oped bloodvessels and lymphatics and the increased vascular tension 
induce a condition of softening and infiltration which causes the vulva 
to gape and to appear particularly prominent. The venous turgescence 
gives to the vulva a dusky hue. The increased vascularity results in a 
condition of great functional activity on the part of the sweat-glands 
and sebaceous follicles. 

The Pelvic Floor undergoes a downward displacement during preg- 
nancy, which by the end of gestation results in nearly doubling the 
skin-distance from symphysis to coccyx. 

The Articulations of the Pelvis are softened by an increased vascularity 
of the inter-articular cartilages. The symphysis pubis is the joint most 
affected ; it is to an extent loosened, thus permitting a limited degree 
of mobility toward the end of pregnancy. As a rule, these changes in 
the articulations contribute very little to the enlargement of the pelvis. 
Should they become pronounced, they may give rise to great incon- 
venience in locomotion. The sacro-coccygeal articulation is mobile in all 
women during the first fifteen years of the child-bearing period, and 
during the expulsion of the child permits recession of the coccyx to the 
extent of one inch. 

General Changes. Pregnancy is the cause of numerous and impor- 
tant changes in the maternal organism at large. Although different 
parts of the body and numerous physiological functions are involved, they 
are not all equally affected. These changes are manifest particularly 
in the nervous and the circulatory systems. Pregnancy being a physi- 
ological process, the organism displays great adaptability in meeting 
these changed conditions. The pregnant woman breathes, provides nour- 
ishment, secretes and excretes not only for herself but for the growing 
foetus as well. The normal woman is perfectly able to meet these addi- 
tional demands when occurring within certain limits, beyond which 
disturbances of health are likely to supervene. In most instances there 
is an apparent improvement in the general health during gestation^ as 



CHANGES IN THE MATERNAL ORGANISM. 123 

though an extra store of energy were being accumulated for the coming 
ordeal of parturition. 

Circulatory Changes. Headaches, ringing in the ears, flushed 
face, cardiac palpitation, and dyspnoea, which are common symptoms of 
pregnancy, led the older practitioners to think that there was present a 
condition of plethora, in consequence of which, thirty-five years ago, 
it was a common practice to perform venesection upon pregnant women. 
Now that the blood conditions are better understood, such practices 
have very properly become obsolete. 

The blood is somewhat altered in composition and increased in quan- 
tity. Extreme changes, formerly believed to take place, do not occur in 
healthy gravida. During pregnancy the watery elements and the pro- 
portion of white corpuscles are increased. In general, the albuminous 
constituents are diminished. After parturition large quantities of excre- 
mentitious material, from both the foetal and the maternal organisms, 
are thrown into the blood. It is reasonable that the blood should be 
increased in quantity during pregnaucy, for the amount necessary before 
gestation would be inadequate to meet the additional requirements of 
foetal nutrition. The condition is not a true plethora, but simply an 
increase in the amount of serum. The diet of the pregnant woman, as 
well as her hygienic surroundings, profoundly affect the quality of the 
blood. Unsuitable diet and unhygienic surroundings may cause a 
condition of marked anaemia and hydrsemia. The extra nutritional 
demands must be met by careful attention to the two elements men- 
tioned. Changes in the blood are most pronounced at the close of ges- 
tation, the decided increase in the fibrin factors is often evidenced by 
thrombotic tendencies at this time and shortly after labor. 

Disturbances often follow these changes in the circulatory system. 
At first, palpitation is purely sympathetic in character, but latterly the 
pressure on the diaphragm from the growing uterus interferes directly 
with the heart's action. (Edema not infrequently results from the alter- 
ations in the character of the blood. 

It has long been taught that the left side of the heart undergoes hyper- 
trophy in the gravid woman. It has recently been shown that there 
is no actual increase in the size of the heart during pregnancy. The 
apparent enlargement is due to displacement. That no hypertrophy 
occurs has been proved by observations upon the weight of the heart in 
women dying in the later months of gestation. No increase in weight 
has been observed to meet the increasing demand upon the circulation 
as pregnancy advances. 

The spleen increases in size, as does also the liver. Fatty degenera- 
tion occurs in both viscera. The thyroid gland, by reaspn of its nutri- 
tional and circulatory relations, undergoes an increase in size, aud in 
women who possess a tendency to enlargement of this gland, pregnancy 
may still further stimulate its growth. 

Eespiratory Changes. The enlarging uterus acts mechanically to 
modify respiratory movements. Upward pressure upon the diaphragm, 
reducing the longitudinal diameter of the chest, prevents free respiratory 
action, notwithstanding the fact that the transverse diameter of the lower 
thorax is increased. As the end of gestation approaches, the uterus 
sinks slightly, thus materially relieving the hitherto embarrassed circu- 



124 PHYSIOLOGY OF PREGNANCY. 

latioa and respiration. Since, during pregnancy, the quantity of blood 
to be purified is increased, it follows that there must be an increase in 
the amount of carbonic-acid gas excreted by the lungs. Cough and 
dvspnoea may be entirely sympathetic when occurring daring the early 
months of pregnancy, but in the later weeks there exists a distinct 
mechanical cause for such symptoms. Such evidences of disturbance are 
more frequently the result of a twin pregnancy, or of amniotic dropsy. 

Nutritional and Digestive Changes. Upon the digestive sys- 
tem rests the responsibility of providing nutritional elements to meet the 
greater demand. Larger quantities of food are required, and it follows 
that there must be an increase in digestive activity, as well as additional 
work for the excretory organs to perform. Digestive disturbances, 
including nausea and vomiting, are so common in the early months as to 
be an almost constant concomitant of pregnancy. They are present in 
the vast majority of cases during the second and third months, gradu- 
ally disappearing as pregnancy advances. With their cessation, appetite 
usually returns, the digestive activity is increased, and there is marked 
improvement in the general nutrition. Irrespective of the growing 
uterus and ovum, and often even despite nausea and vomiting, there is 
normally a steady gain in body-weight. Although constantly progres- 
sive, the gain is most marked in the last two months, and for the entire 
period of gestation it amounts to from ten to fifteen pounds. The fat is 
the tissue most largely increased; it is deposited particularly in the mam- 
mary glands, about the buttocks, in the abdominal parietes, and omen- 
tum. The figure becomes fuller and rounder. This increase of stored 
potential energy is to be utilized after delivery, when the physical powers 
are taxed by lactation. 

Puerperal Osteophytes sometimes develop on the inner sur- 
face of the frontal and parietal bones. They are irregular in outline 
and are composed of calcium carbonate, traces of phosphates, and organic 
matter. They are not peculiar to pregnancy, and may sustain some 
relation to the calcareous changes in the placenta and to the forthcoming 
milk secretion. 

There is no material alteration of the body temperature during preg- 
nancy. 

Changes in the Skin, the Gait, and the Osseous System. 
The hair follicles, the sebaceous and sweat glands are more active during 
pregnancy. It has been stated that the growth of hair is invigorated at 
this time. Pigmentations, occurring in isolated patches over the body, 
are often observed; these are particularly noticeable upon the abdomen, 
the face, and around the nipples, the primary and secondary areolae. A 
dark pigmented line, the linea nigra, is frequently observed extending 
from the umbilicus to the symphysis, and sometimes continued to the 
ensiform cartilage. These pigmentations vary in different subjects, being 
more marked in brunettes than in blondes. After parturition they are 
diminished in intensity, but rarely disappear. 

In pregnancy there is a marked change in the gait and carriage, par- 
ticularly noticeable in short women. In order that the equilibrium may 
be maintained, the head and shoulders are thrown backward. 

Because of the drain on the osseous elements of the blood, a fracture 
occurring during pregnancy does not unite readily. 



CHANGES IN THE MATERNAL ORGANISM. 125 

Urinary Changes. The kidneys, which are supposed to be en- 
larged, furnish a more abundant supply of urine of a lower specific 
gravity. This functional activity is due to increased arterial tension. 
The qualitative changes in the urine are an increase in the chlorides, and 
a diminution of the phosphates and sulphates, which are used by the 
growing foetus. The pellicle, kiestein, often found upon the cold urine 
of pregnant women, is not peculiar to pregnancy; it is observed under 
other conditions, and even in the opposite sex. 

Sometimes iactose makes its appearance in the urine during the later 
weeks of pregnancy, and during beginning lactation. The proportion 
depends upon the relation of supply and demand, diminishing as the 
balance is established. 

The writer has determined by observation of a large number of cases 
that from 5 to 10 per cent, of pregnant women have albuminuria, usually 
small in quantity and extending over short periods only. It is more 
likely to be present during parturition than pregnancy, and is especially 
apt to follow a long and difficult labor. 

Changes in the Nervous System. Marked changes in the mental 
characteristics of the woman are common. She may become fretful, 
peevish, irritable, and at times unreasonable. The tendency to emo- 
tional disturbances is increased. The nervous system becomes extremely 
impressionable. Home surroundings, whether agreeable or not, may 
exert a profound influence, either for good or for evil. Slight ailments, 
which at other times would affect the nervous system but little, may 
have an exaggerated import. These symptoms may progressively increase 
in intensity till during the latter part of pregnancy, or soon after labor 
temporary or even permanent melancholia or mania may result. 



CHAPTER IV. 

DIAGNOSIS OF PREGNANCY. 

Method, clearness, and perspective are not more necessary to the 
student in learning the signs of pregnancy than is the acquisition of a 
habit of orderly procedure to the practitioner in making a diagnosis of 
this condition. The difficult cases are many; the result of error is ridi- 
cule. Vander Veer has collected sixty-eight instances of operation on 
supposed pathological growths, some of the operators being men of note. 
The laity imagine that it cannot be hard to tell whether or not there is 
a child in the womb, and often insist upon a positive conclusion. This 
demand is strongest in the early weeks when the signs are fewest and 
faintest. A relatively large amount of space has, therefore, been accorded 
to the changes in the second and third months, and to their literature, 
whereas the later major signs are our common property, whose history 
may be omitted in this short chapter. 

In addition to the main question — whether certain indications are or 
are not present — the examination will necessarily touch on the possibility 
of the diseases that simulate each sign; the estimate of the period to 
which gestation has advanced, in order to collate all the signs due at 
that period, and the queries whether the pregnancy is normal or abnormal, 
the child alive or dead. Many other facts, very nearly connected with 
the subject-matter of this chapter, but more commonly inquired into a 
month before labor, are relegated to the antepartum examination, which 
may be found under the chapter on the Management of Labor. In quiz- 
zing, one asks concerning each sign: what its character is, its cause, the 
method by which it is brought out, its location, the date of appearance 
and duration, and what conditions other than pregnancy may counterfeit 
or develop it. Only through bedside instruction can the student learn 
the look of the areola or acquire skill in palpation and auscultation. 

The four steps of the examination follow an obvious order : Historv 
from the patient; physical exploration, mammary, abdominal, pelvic. 

I. History. 

The chief symptoms obtainable from the patient are cessation of men- 
struation, nausea, enlargement of the breasts and abdomen, and quick- 
ening. 

Suppression of Menses. After conception menstruation ceases. This is 
usually the first sign to draw attention to the condition. "Ina woman 
of previously regular menstrual habit, and in the absence of other appre- 
ciable causes of amenorrhoea, the arrest of the catamenia is to be regarded 
as strong presumptive evidence of pregnancy." 1 The importance of 
this evidence increases after the second omission, since belated appear- 

1 Essentials of Obstetrics, by Charles Jewett. Lea Bros. & Co., Phila., 1897. From this book the 
writer's classification is mainly drawn, with much more besides. 

(126) 



DIAGNOSIS OF PREGNANCY. 127 

ance of the flow for a few days to two weeks is not uncommon. It is 
most weighty, as indeed may be said of all the signs, when it corresponds 
in time with the size of the uterus and the usual date of appearance of 
the other evidences of pregnancy. 

Three things lessen the value of this sign : 

a. There are other causes of amenorrhoea. These are mainly anaemia, 
tuberculosis, chilling, delay in menstruation, emotional causes, nephritis, 
as well as change of climate, obesity, the menopause, pelvic inflamma- 
tions and tumors, and an irregular menstrual habit. Newly married 
women or those fearful of the results of wrong-doing are rather prone 
to run over their time ; the sea voyage checks the flow with our immi- 
grants ; or the climacteric may arrive early. 

b. An apparent menstruation may take place in early pregnancy. This 
is infrequent, so that a woman who is unwell regularly, however scantily, 
is almost always wrong in her suspicion of pregnancy. When a periodic 
flow does occur during gestation — and a woman calls any more or less 
periodic flow her courses — careful questioning will elicit evidence of 
lessened quantity, a thin or serous character, or some variation in typical 
increase and tapering off. Such flow rarely takes place after the third 
month, when the decidua reflexa and vera have no longer a cavity 
between them. The source lies usually in some lesion of the cervix, in 
an endometritis or polyp, or even in a placenta that is prsevia. A 
patient illegitimately pregnant not infrequently denies amenorrhoea, or 
places the last period later than the true time. The denial may be 
volunteered in the hope that during local treatment a sound will be 
passed. A few cases have been reported wherein menstruation appar- 
ently continued throughout pregnancy, or took place then only. 

c. Pregnancy sometimes begins in patients not menstruating. Concep- 
tion may occur before the function is established, as is de rigueur among 
certain of our Indian tribes; or after the function has ceased; or it may 
take place during the physiological amenorrhoea of lactation; or, lastly, 
in those who are in the habit of skipping periods. It should be said also 
that impregnation happening just before a period may affect it little. 

Nausea and Vomiting. This is a frequent accompaniment of early preg- 
nancy, ranging from an occasional qualm to inability to retain any food. 
It is a reflex from the stretching of the uterine muscle-fibres and nerves 
or from pressure in the pelvis. Occurring late in pregnancy, pressure and 
displacement explain it. The grades or degrees may be placed in the 
following clinical groups : (a) Nausea absent or slight in a considerable 
percentage of cases ; (6) nausea with occasional vomiting during the 
second and third calendar months (fourth to thirteenth weeks) — a very 
common condition ; (c) long-continued, distressing, debilitating, but not 
dangerous, retching and vomiting; (cl) vomiting imperilling the health, 
and (e) threatening life. The disorder is generally a morning sickness 
on first rising, or may be only after meals, or solely when the stomach 
is empty. Infrequently it begins soon after conception, and may last 
throughout gestation. 

Its value as a witness to pregnancy is scant, since it occurs in gastric 
catarrh, chronic nephritis, and as a reflex in pelvic disorders and many 
others. If it has always appeared at a given time in previous pregnan- 
cies, it has some weight. 



128 PHYSIOLOGY OF PREGNANCY. 

Salivation many times accompanies the sickness. The secretion is 
tenacious and difficult of expectoration, hence the name " spitting cot- 
ton. " Heartburn, abnormal appetites, longing or loathing toward vari- 
ous strange articles of food, toothaches, and the like, may be present. 

Enlargement of the breasts, with throbbing, tingling, stretching ful- 
ness, or secretion, may be complained of', with tenderness of the nipples, 
and the patient may have noted that her clothes are too tight, but all 
these are matters belonging to the physical exploration. \Ye need only 
mention irritability of the bladder and altered or perverted sensations^ 
to dismiss them as of no moment. 

Quickening is the sensation imparted to the mother by foetal move- 
ments, from the least tremulous flutter to painful somersaults that keep 
her awake with acute pain. The motion is usually perceived midway 
in pregnancy, yet may be felt in pregnancies other than the first as early 
as the third month, or it may never be discovered throughout. Its 
importance lies wholly in the mind of the laity. Movement of gas in 
the bowel counterfeits it, and muscular contractions in the belly wall. 
Or the sensation may exist only in the imagination. Cessation of motion 
may be due to death of the foetus, but temporary or even permanent 
stoppage of these feelings on the mother's part is not incompatible with 
a living child. 

II. Mammary Sigxs. 

Summary of Signs and Approximate Date. 

1. Increased size ; nodular feel "1 

2. Veins ..... 

„ „, . . , . t ' " . }■ End of 2d month. 1 

3. Changes in primary areo±a ; pigmentation, elevation, 

■wrinkling, follicles ........ J 

4. Milk 3d month. 

5. Secondary areola 5th month. 

1 . The Breast Enlargement of pregnancy differs from simple fat deposit 
by the firmness and knotty, uneven character to the touch. This is due 
to increase in size and number of the glandular lobules, swelling of the 
connective tissue, and increased deposit of fat between the lobules. In 
the early months the change is to be distinguished most clearly at the 
edge, but later the strings of nodules or tiny grape-clusters seem to 
extend toward the centre. Still later a certain relaxation in the whole 
breast is seen. The tension may stretch the skin into silvery lines, like 
the striations on the abdomen, and these constitute permanent markings, 
often purplish in color. 

2. The Veins enlarge, forming a blue tracery under the skin or slightly 
elevated above it. They run across the breast and into or around the 
areola. To bring them out fully the centre of the breast may be circled 
with pressure for a moment, preferably in a bright light that strikes the 
surface obliquely. 

3. The Primary Areola. Pigmentation. The darkened base on which 
the nipple stands becomes in women of the brunette type the seat of a pig- 
ment deposit that renders it not unlike the tint of the negro's skin, ranging 
from reddish-brown and brown to black, the depth of color usually de- 
pending on the patient's complexion. In very light blondes there may 

1 In this chapter the word " month '' denotes the calendar month 



DIAGNOSIS OF PREGNANCY. 



129 



be no discoloration, though often, even when pigment is not visible, red- 
dening or a congested look is noticeable—" the delicate rose-color ; > of 



Montgomery. 



Fig. 130. 



Fjg. 131. 







Brunette. Pigmented primary areola ; slight Brunette. Wrinkling of primary areola. Well- 

secondary areola. denned secondary areola, S. A. 



Fig. 132. 



Fig. 133. 



Blonde. Follicles, F. Milk. Faint 
secondary areola. 



Blonde. Elevation (E) of primary areola. Follicles. 
Secondary areola. 



Fig. 134. 




Relaxed breast of multipara. Veins. Secondary areola. 
9 



130 PHYSIOLOGY OF PREGNANCY. 

Elevation of the areola is common in fair women. The puffy thick- 
ening and oedema, raising the surface slightly, level or rounded, like a 
tiny breast on the breast, are readily brought out or accented by gently 
patting the surrounding skin on the stretch. 

Wrinkling or contractility of the areola is produced by the increase 
in sensibility and size of the subareolar muscle. These bands, mostly 
circular, are 2 mm., T 1 F inch, in thickness, according to Testut. Fric- 
tion or cold or emotion will cause contraction, thereby puckering the 
skin of the areola over them, and throwing the nipple forward. This 
is in no sense an erection, although the phenomenon is commonly called 
erectility of the nipple. 

Montgomery's Follicles make up two to twenty small papular 
prominences on the areola, 2-3 mm. high. They are enlarged sebaceous 
follicles, and at times moist, lubricating the nipple. Stretching of the 
skin or action of the muscle of the areola renders them more easily seen. 

4. Milk. Pressure on the breast and a moment's dextrous stroking of 
the ducts running toward and beneath the areola will bring colostrum 
after the third month. There may be branny, dried scales of it on the 
nipple. It is water-like, or slightly opaque, or later, occasionally yellow. 
This is the most important of the mammary signs in the woman preg- 
nant for the first time, but, inasmuch as milk persists in the breast there- 
after, it gives no help in other pregnancies. As a curiosity, it may be 
mentioned that milk has been found in virgins, or has been developed in 
them — -or even in the male — by nursing. The primitive man is sup- 
posed to have helped suckle the young, when families were larger. 

5. Secondary Areola. Where the primary areola fades into the skin 
there appears, at the fifth month, a network of pigment around a certain 
number of light spots, each tiny circle having for its centre the opening 
of a follicle. These washed-out spots are rarely absent altogether, usually 
run about the circumference of the dark surface, and may extend all 
over the breast. Next to the milk this is the most valuable of the 
mammary group in the primigravida. 

Value of the Mammary Signs. ■ In first pregnancies, with no history of 
long-continued pelvic disease, the changes enumerated above furnish 
strong presumptive evidence of pregnancy. They are important in 
conjunction with other signs. All the indications are rarely present at 
once in the same case. After the first gestation the signs remain. Vari- 
ous ovarian and uterine disorders, such as tumors, may bring about 
similar appearances. Masturbation frequently does it, in a certain degree, 
even where the nipple is not handled. 

In practice, breast indications help one in the unmarried suspect. A 
girl with amenorrhcea aud nausea is not to be lightly subjected to biman- 
ual examination or to a question that may be a grave insult; but, under 
the pretext of investigation of the heart or lungs, the sight of a nipple 
that shows distinctive alterations will warrant further steps. 

Finally, if pregnancy exists, we look to the organ's fitness for func- 
tion, and teach the patient to bring out a stunted, creviced, inverted, or 
tender nipple by massage and traction. 



DIAGNOSIS OF PREGNANCY. y>i 



III. Abdominal Signs. 

Summary of Chief Signs and Approximate Date. 
On palpation : 

1. Size of tumor, and typical growth . . From 4th month. 

2. Intermittent contractions 4th month. 

3. Fcetal parts n 

4. Fcetal movements !> $% months. 

5. Abdominal ballottement J 

On auscultation : 

6. Fcetal heart ) 

7. Uterine souffle '. '. ) 4% months. 

Preparation for Examination. With clothing unfastened and opened, 
and all waist-bands loosened, with corsets off and bladder emptied, the 
patient lies down on the office table or on a firm bed or lounge. A 
pillow bends the head somewhat forward on the chest, and the shoulders 
are preferably slightly raised by an inclined plane resembling a bed-rest 
or by a second pillow under the first. This forward curve of the spinal 
column does not extend below the scapula. Such a position, with the 
legs and thighs flexed, relaxes the abdominal walls to their utmost, 
except very late in pregnancy, when a straighter posture is better. A 
sheet covers the legs and trunk ; through this or under this examinations 
may be made in most instances, but one uncovers to listen with the steth- 
oscope or for thoroughness in obscure conditions. 

Warm hands have a more acute sense of touch than cold. Cold con- 
tacts will cause reflex contraction of the muscular walls. Gentle palpa- 
tion may bring out all the facts. The skilful use of some force may 
yet give the impression of light-handedness by gradual increase of press- 
ure. One does not prod with the finger-tips nor play the piano on the 
surface. With the finger edges touching, the facies of the last phalanges 
pass along the uterine walls. This is one kind of touch — the circling, 
sliding contact. The other is a quick push or gentle thrust, to estimate 
the various resistances. The latter gives more information, but is 
resented by a sensitive surface. 

The examination is made in due order : inspection, palpation, auscul- 
tation. 

Inspection. 

Contour. It is said that in the second month the hypogastric region is 
flatter and the umbilicus deeper than normal. Enlargement of the abdo- 
men begins after the third month, as the uterus rises well above the brim 
of the pelvis. Regular increase takes place until two to four weeks 
previous to delivery, when "sinking", or "lightening" occurs, the 
lower pole settling into the pelvis, and the patient experiencing the com- 
fort of easier breathing and looser waist-bands; but, on the other hand, 
disturbed by increased bladder pressure. Typical evidences of settling 
are absent in very many women. 

The protrusion of the belly-wall is not symmetrical, being commonly 
most distinct in the later months to the right of the median line, owing 
to the torsion of the uterus. Fat deposits in the gluteal regions and 
over the hips are noticeable in addition to that in the abdominal wall 
itself. The navel may protrude as the development nears term. 



132 PHYSIOLOGY OF PREGNANCY. 

Pigmentation and Striation. Along the median line of the abdomen a 
dark track of brown is clearly traced from the pubes around the navel 
and up to the ensiform cartilage. It is discolored most in those with 
darker skins, and is one-eighth to one-half inch in width. It is part of 
the pigment dropped in places where capillaries are few, along the front 
foetal closure line, on the lips, abdomen, vulva, and perineum (Ahlfeld). 
The other pigment markings or spots on the face and body are mostly a 
vegetable growth (chromophytosis). The darkened abdominal line may 
be found in boys, in virgins, in brunettes, and in pelvic disorders. This 
change begins in mid-pregnancy. 

Streaks or striae, resulting from stretching of the skin, appear on the 
lower abdomen. These " linese albicantes" vary in color from silvery 
white through pink to bluish and faint purplish tints. They are wavy 
and irregular, and in direction commonly lie in concentric zones around 
a centre just below the umbilicus. They belong chiefly to the last 
trimester. The skin injury is permanent. On the breasts, the thighs, 
and the buttocks the markings are also seen. 

Value of Inspection Signs. Any other cause for abdominal enlargement 
or skin tension will produce like effects; therefore, these things are of 
no import. We enumerate them for completeness in description. 

Palpation. 

The signs brought out bv this means are : Size of uterine tumor and 
regular growth, intermittent contractions, foetal parts, foetal movements, 
and abdominal ballottement. 

Size. The fundus may be felt as it begins to rise two or three fingers 
above the symphysis in the fourth month (sixteenth week). At about 
the sixth calendar month (twenty-sixth week) the navel is reached, 
although this landmark varies so greatly in its distance from the pubes 
and ensiform that it constitutes a measure of no great accuracy. The 
ensiform is reached with the maximum height at eight and one-half 
months (thirty-sixth week), while at term the rounded upper limit of 
the uterus is somewhat lower. To find the fundus most readily the 
hand is laid transversely above the expected level, and its ulnar border 
depresses the abdominal wall; this edge works slowly downward until 
the uterus is capped by the bowed hand. 

To be of value the development of the organ must be progressive and 
correspond in a general way to the supposed duration of pregnancy as 
evidenced by other signs. Advance is most rapid in multigravidse, par- 
ticularly where the abdominal muscles are Jax, the whole organ standing 
high out of the pelvis; with twins or hydramnion, and in vesicular mole. 
In certain cases no sinking of the fundus occurs, nor is it found where 
the muscular layers lack tone, or where an obstruction or a placenta 
holds the presenting part up out of the pelvis. The factors affecting 
the height are so various that exact figures possess scant value. 

Incidentally note is taken of pendulousness of the abdomen, excessive 
fat deposit, diastasis of the recti muscles, and tumors in the uterine walls 
or in the neighborhood. 

Foetal Parts. The characteristic to the touch which differentiates 
this tumor from other smooth, ovoid, or pear-shaped semi-fluctuating 



DIAGNOSIS OF PREGNANCY. 133 

cyst-like growths, is that some parts are harder, some softer; that the 
solid parts are of various sizes; that these surfaces and knobs can be 
identified as actual parts of a child — more particularly as the limbs and 
head and back. These landmarks may disappear under a general resist- 
ance as the womb-wall contracts, to reappear as the tension passes off. 
Occasionally the face or the feet may be distinctly recognized. 

Foetal parts clearly felt furnish one of the two or three best signs of 
pregnancy. It is most uncommon to find a tumor bearing distinct resem- 
blance in shape to a foetus. In cases of excess of liquor amnii or tender 
or tense uterine walls, one may be unable to outline the child. Foetal 
parts may be detected in the sixth month or a little earlier. 

Foetal Movements. The hand laid quietly on the abdomen detects a 
thrust or push within the womb. Early, it is felt as the gentlest of 
throbs. Later the motion is either general or local; either the entire 
body changes its position by partial rotation, with a rolling, sliding 
motion, or else quick blows are dealt at one or more spots; or, finally, 
a prominence travels along under the lifted skin. To bring out such 
action in a quiescent foetus one may have to gently push or toss the child. 
The motion is most easily developed at one cornu where the feet are 
found. 

This sign, when clearly detected by the examiner, ranks with the last 
in importance. It may be simulated by bubbling of gas in the bowel 
or by localized contractions of the abdominal muscles. These resem- 
blances are said to be occasionally very deceptive, and women themselves 
are not infrequently deceived, but patience should always give the 
medical man certainty. Sometimes the motions are rhythmic. Failure 
to detect movements does not necessarily mean a dead child nor exclude 
pregnancy. 

The date of detection depends on one's skill, in part. By the time 
the foetus is a foot long the impulse is vigorous enough to feel — that is, 
by the sixth month — often earlier. 

External Ballottement. This is the sensation imparted by a displaceable 
mass floating more or less freely in fluid. A hand on either side of the 
fundus, the operator facing the mother's face, may be able to push an 
irregular bulk to and fro; or the foetal part may be rapidly moved under 
the hand; or, typically (therefore seldom), the fingers may, with a light, 
quick thrust, drive away a ball that bobs back again against their tips. 
This distinctive " dipping" and return, or repercussion, is only felt by 
the route of the abdomen in cases with abundant amnial fluid, or in thin 
persons, in the fifth month, through the fundus. The best demonstration 
of this sign is to be had when the head is in the fundus and is cast to 
and fro as it balances over the shoulders. 

The date of detection of this form of tossing is usually after the uterus 
has risen well into the abdominal cavity — the sixth month. The value 
of the sign is great, and only pedunculated tumors or wandering organs 
like the kidney are likely to simulate it. 

Intermittent Contractions. A rhythmic and painless hardening of the 
uterine walls occurs every five to ten minutes, lasting from one-half to 
five minutes. The contractions may be elicited by friction or by the 
touch of the cold hand. These alterations in tension are noted as soon 
as the fundus is high enough to grasp — that is, from the fourth month; 



134 PHYSIOLOGY OF PREGNANCY. 

but by conjoined manipulation are appreciable from the earliest begin- 
nings of pregnancy. 

This sign has a definite value as showing a condition of hypertrophy 
of the muscular wall of the uterus, and because the disorders that like- 
wise develop this reflex are infrequent. A uterus distended by retained 
menstrual blood (hsematometra), or by a soft uterine fibroid, will act in 
the same manner. A greatly distended bladder will give the same 
sensations. 

In practice the muscular contraction is of service also, because the rigid 
round ligament gives us knowledge of the seat of the placenta, informa- 
tion especially desired in case of Cesarean section. 

Percussion is infrequently employed because we can map out the gravid 
uterus otherwise. In tense abdomens it serves. It may be stated as 
a rule that after the fifth month the uterus is always in contact with the 
front wall of the trunk-cavity with no intestinal loops intervening. 

Auscultation. 

The ear brings out four evidences of pregnancy: Foetal heart, uterine 
and umbilical murmurs, and foetal shock. 

Foetal Heart. The sound is generally doubly like that of the adult 
apex, and at a rate nearly twice that of the maternal pulse. It has been 
often compared to the muffled tick-tack of a watch under a pillow. A 
clearer notion may be acquired by the student who listens through an 
infant's back. To count it calls for practice on his part, but skill comes 
with persistence and arms him for two important occasions. 

The rate is between 120 and 150, and may be increased by the activity 
of the child and by fever of the mother. The rapidity is greater at the 
beginning of a pain, slowing as the pressure increases (seldom dropping 
below 100), even ceasing momentarily at the acme. Variations of 20 
beats in the same foetus are frequent. Sex cannot be determined by the 
rate. Boys and larger children were supposed to have slower heart- 
action than girls and smaller children, and the percentage does fall a 
little in their favor, but the Frankenhauser theory, that this is reliable 
or even an approximate index of sex, is discarded. 

The heart is heard most commonly between the navel and the anterior 
superior spine of the ilium on the left side, because the back of the child 
is located there in the usual position, the left-occipito-anterior. If the 
previous palpation has indicated that the back will be found in some 
other place, we listen in that spot, and confirm the diagnosis of position. 
In the flexed foetus the heart is placed as near one extremity as the 
other; it is heard below the navel when the head presents, because the 
head sinks into the pelvic brim. Should the breech present, the focus of 
greatest intensity late in pregnancy will be above the umbilicus or at its 
level. There is some property of the living tissues that prevents the 
heart from being heard over an area larger than 2 to 4 inches, 5 to 10 
cm. A second focus may be detected at the spot where another part 
of the child presses against the wall, or in case of twin pregnancy. 
Faint hearts are heard over a small area. Occasionally a wide diffusion is 
encountered. 

The date at which the heart may be heard is a little after mid-preg- 



DIAGNOSIS OF PREGNANCY. 

Fig. 135. 



135 




Defective method of listening to foetal heart ; the neck is bent, the middle ear congested. Exami- 
nation is here shown on the low cot, as it corresponds to the bed or sofa in private practice. 



Fig. 136. 




Defective method of listening for the foetal heart by standing and leaning over. The fulness of th€ 
cerebral vessels caused by this position is indicated in the distended veins on the forehead. 



136 



PHYSIOLOGY OF PREGNANCY. 



nancy; the time is somewhat dependent on the skill of the observer. 
It is said to be audible in some cases as early as the fifteenth or sixteenth 
week. 

In value, no sign compares with this. It is certain. The chief fallacy 
lies in mistaking for it the aortic pulsation transmitted through the uter- 
ine mass, or arterial pulsation on its surface, or the sound of the maternal 
heart. A finger on the radial of the mother establishes the connection 
with her heart, or the reverse. Moreover, a transmitted maternal cardiac 
impulse grows stronger in tone as the ear works upward toward her chest. 
Occasionally one finds that he is listening to the pulse in his own ears. 
The only troublesome uncertainty will occur when the mother's heart is 
acting excitedly at about the same rate as that of the child, as after long 
labor or hemorrhage. 

Fig. 137. 




Better position for listening to the foetal heart ; straight neck, easy posture, fingers on radial. The 
assistant presses on the fundus. 

The heart is rendered faint or inaudible by an occipito-posterior posi- 
tion, a very fat abdominal wall, excess of liquor arnnii, anterior attach- 
ment of the placenta, by loudness of the uterine souffle, or persistent noise 
of gas in the bowels. Death of the child does away with this sound, of 
course ; but repeated observations of such absence may be necessary for 
positive diagnosis, together with default of movements, lack of tone in 
uterine wall and breasts, and the recession of other signs. 

Method of Examination. Prepared as described on page 131, the 
patient is to lie preferably where she is accessible on both sides, as 
on a table or couch. The stethoscope is used for early or difficult 
cases ; but on this yielding surface many observers find that more can 
be accomplished with the ear. It is expedient to train the ear, for 



DIA GNOSIS OF PREGXA NC Y. 137 

one does not carry a stethoscope in an obstetric bag, and the most im- 
portant facts obtainable from foetal heart-sounds are those gotten in the 
systematic examinations during the progress of the labor, namely, con- 
cerning the danger to the foetus or the need of prompt interference. A 
single unstarched thickness is not a hinderance to auscultation, as a rule. 
If the listener stands and bends over, or if his collar presses against the 
jugular vein, congestion of the inner ear will interfere with fine hearing. 
To hear best, if standing on the left of the patient (or with a better right 
ear), one kneels at the edge of the bed near the patient's shoulder, 
facing toward her feet. The right ear is laid rather firmly against 
the lower abdomen, compressing the fat layers. To auscultate the right 
side one may kneel opposite the hips and reach across the patient at right 
angles, or pass to the other side. A relatively long count is desirable — 
say, thirty seconds — and should gaps occur in the succession of the 
sounds, one counts steadily across them at the same rate. A hand 
placed on the fundus, pressing toward the pelvis, will arch the child's 
back up toward the listener's ear. Patience, and persistence, and favor- 
able conditions are all requisite at times, while a room without a clock 
and away from street and house noises may be necessary. 

Apart from our subject, the foetal heart has great value in the deter- 
mination of presentation and position; of plural pregnancy; in deciding 
whether the foetus is alive or dead; as a danger signal in labor, a rate 
persisting below 100 or near 200 calling for interference to save the 
child. 

Uterine Souffle. A murmur synchronous with the mother's pulse is 
heard along the left side of the uterus. It resembles the bruit in the 
neck of anaemic girls, and the sound is of a quality entirely unlike the 
tap of the foetal heart. If the hand is laid in an arch over the ear and 
its back lightly brushed with the finger-tip, a semblance of this murmur 
may be had. Its source is the blood-rush in the enlarged and tortuous 
uterine vessels; it is usually heard loudest, therefore, along the sides of 
the uterus, and particularly along that side, the left, which is turned 
toward the anterior abdominal wall. Here the stethoscope serves best, 
as the murmur is first hunted for in the sulcus above the middle of 
Poupart's ligament, and from that point upward, with rather firm press- 
ure. The murmur is heard earliest in the middle line. Late in preg- 
nancy it may be found all over the uterus; though often it is entirely 
wanting, or, more commonly, is capricious, appearing and disappearing, 
being strongest during the early part of a contraction. It grows louder 
as pregnancy advances, and is most marked in ansernic women. 

The uterine murmur becomes audible during the fourth month. It 
persists after the delivery of the placenta. It is a valuable sign of an 
enlarging uterus, but lessened in importance as proof of pregnancy by 
its presence with large uterine fibroids, or even in association with 
ovarian cysts or chronic metritis. 

Funic Souffle. The umbilical murmur is synchronous with the foetal 
heart, and heard usually over the child's back. It is produced by ten- 
sion, pressure on and displacement of the cord, originating, as a rule, in 
the umbilical vein (Winckel). In some cases it may originate in the 
heart itself — even in an endocarditis (Bumm). The sound is heard 
more frequently when the cord is coiled about the foetus, when the cord 



1 38 PHYSIOL OGY OF PBEGNANC Y. 

is abnormally short or long, or when it is deformed — e. g., when the 
insertion is velamentous. Hence, this bruit furnishes an index of a 
certain amount of dauger to the child, according to Winckel. It is 
heard after mid-pregnancy, but is relatively rare in the writer's expe- 
rience. 

Foetal Shock. In listening with the stethoscope as early as the third 
or fourth month (fourteenth to sixteenth week) the trained ear may some- 
times get the tiny thud, with the sound that accompanies it, produced by 
foetal impact. The tap of the finger on the back of the hand held near, 
but not in contact with, the ear, is not unlike it. Winckel says it occurs 
in 1.0 to 15 per cent, of all cases. Gas moving distantly in the bowel 
somewhat resembles it. 

IV. Pelvic Signs. 

By vaginal and abdomino- vaginal examination the chief indications of 
pregnancy are : Purplish hue ; softened cervix ; compressible isthmus ; 
bulging, elastic corpus ; vaginal ballottement ; foetal parts. 

Method of Examination. The details concerning loosened clothing, 
coveriugs, and the dorsal posture, with elevated head and shoulders, have 
been given on page 133. Just before lying down the patient is requested 
to urinate. When an early diagnosis is urgently desired, and the rectum 
is loaded, an enema may be given; or if the bowels are much distended 
with gas a second examination is asked for, and a three-day diet, mostly 
of meat, fish, eggs, and milk, is ordered, together with a laxative, and, 
perhaps, a tablet containing charcoal, pancreatin, bismuth, and ginger. 
To lift the small intestine out of the pelvis and secure access to the rear 
of the uterus, particularly in retro-positions, the injection of air into the 
rectum with the patient in the knee-chest or latero-prone posture is 
worthy of trial (Kelly). Nitrous oxide or chloroform are final resorts. 
By all these means tension is lessened and the reach down into the 
pelvis facilitated without some of the harsh methods originally counselled 
by Hegar. 

In order to put the muscles of the pelvic floor and those of the abdom- 
inal wall, as well as the adductors, at a disadvantage, the patient is 
brought down to within a foot of the near edge of the table, the feet 
placed eight or ten inches apart, and the knees spread abroad to their 
utmost. If a bed is used it should be firm, that the buttocks may not 
sink into it. The patient lies at a right angle with its length. Five min- 
utes' scrubbing of the hands should be a routine preliminary to vaginal 
examination, because of the special susceptibility of the gravid woman 
to infection, because the finger may need to explore within the cervix, 
and because, if premature interruption of the pregnancy should soon 
occur one might have infected his patient. The vulva is cleansed. One 
passes the finger in by sight in order to make no unnecessary contacts, 
especially with an imperfectly cleansed anal region; the left hand draws 
the labia wide apart so that the first contact of the examining finger or 
fingers will be with the hymen or the vaginal wall inside it. Here 
again, by gentle firmness, a long reach is practicable, the web be- 
tween the fingers carrying the perineal body far backward and 
inward. 



DIA GNOSIS OF PBEGNANC Y. \ 39 

If possible, the uterus is gently and quickly caught between the two 
hands and examined. If out of easy bimanual reach, the finger tips 
are slipped beyond the cervix and hooked forward, lifting the uterus 
bodily toward the anterior abdominal wall through the intervening intes- 
tinal coils. The outer hand depresses the hypogastrium to reach low 
down on the back of the uterus, or gently makes circling massage move- 
ments with gradually increasing pressure as the muscles yield. The 
patient is told to cough or breathe deeply, or her attention is side-tracked 
by a question. In these ways, quickly tried, the hands, one on each face 
of the uterus, reach as far toward the cervix as may be. Beginning at 
the cylindrical neck, the anterior and posterior surfaces are examined 
from cervix to fundus, for compressibility just above the cervix, next for 
bulging of the walls of the body, following the profile and estimating any 
increase in thickness of it, determining at the same moment its consist- 
ency, whether resiliency is present or not, and, lastly, swinging the body 
from side to side over the stationary inner fingers to appreciate breadth 
and the denser spot. The cervix should be palpated at first no more 
than is necessary in order to identify it, for manipulation here quickly 
induces intermittent contractions, whereby the organ hardens and some 
of the signs disappear. As an alternative, the uterus may be toppled 
over backward and the thinned isthmus brought between the fingers of 
the two hands. 

Whenever the fundus lies in the sacral hollow and cannot be 
swung forward, a tenaculum hooked into the cervix will draw down 
the uterus within reach of vagino-abdominal or recto-abdominal pal- 
pation. 

Inspection of the cervix for color-changes, with the speculum, is next 
in order. A miscarriage subsequent to a speculum examination may be 
attributed by the patient to the physician's " instruments " either through 
ignorance or by a woman who afterward induces abortion. With certain 
patients one avoids any examination except the bimanual, which can do 
no harm. 

Kectal examination gives little information in normal cases, but is 
necessary in uterine or ovarian displacement, or to outline and differen- 
tiate tumors, exudates, or hemorrhages. 

Purplish Hue of the Vagina. Venous congestion from hypertrophy of 
the vessels runs up the entire vagina. On drawing the vulva open the 
dusky discoloration is seen readily on the anterior vaginal wall below the 
urinary meatus. A faint venous color may show itself by the end of 
the first month. Chadwick showed that 80 per cent, of pregnant women 
developed the color by the end of the third month. The fallacy is that 
heart disease, varicose enlargement, and the like may produce analogous 
coloring. Late in pregnancy the pudenda are relaxed, soft, and swollen, 
while moistened by free secretion of mucus. 

Purplish Hue of the Cervix. "A more or less marked lividity of the 
vaginal portion of the cervix may be observed almost from the first 
month after conception. The purplish color of the cervix is not only 
developed earlier, but is more constantly present than that of the vagina" 
(Jewett). 

Enlarged arteries are felt pulsating in the vagina, often suggestive oi 
foetal movements or ballottement. 



140 



PHYSIOLOGY- OF PREGNANCY. 






Early Changes in the Uterus. Six or eight weeks after the beginning 
of the last menstruation the following conditions are found : 
I. In the isthmus between body 
and cervix 



II. 1 

III. | 

IV. | 

i 
V. i 

VI. j 

VII. ) 

VIII. i 



In the bodv of the uterus 



In the 



cervix 



Compressibility. 

Elasticity or doughiness. 

Bulging, symmetrical or irregular. 

Density differences between right 
and left sides. 

Furrows or folds. 
v Intermittent contractions, 
f Softening. 
( Purple hue. 



Of these signs, the first three are most valuable ; in frequency they 
rank in the opposite order, namely, bulging, elasticity, compressibility. 

Compressibility of the Lower Uterine Segment. Just 
above the cervix and between it and the rounded body above there is a 



Fig. 138. 




Changes in the pregnant uterus of the sixth week, on the left when partly relaxed, on the right 
when contracted. Diagrammatic side view. 

striking absence of resistance, the fingers of the examining hands coming 
together closely. When the sign is fully developed the thickness is no 
more than that of a visiting-card. In its extreme form the corpus seems 
like a tumor pedunculated. Often the yielding sensation is partial, yet 
unmistakable. It is accounted for by reference to the section of 
Pinard's uterus (Fig. 139), imagining the bulk of this ovum as some- 
what less, for the enormously thickened mucosa contains many dilated 
and irregular blood-sinuses which reach their maximum development at 
the end of the second month, and the decidua is very pulpy and soft. 
Well-defined compressibility was found by the writer in two-thirds of a 
series of fifty cases. 1 Of all the bimanual signs of early pregnancy, 
this is the most important. It is known as " Hegar's sign." 

Bulging of the Corpus Uteri, Symmetrical or Irregular. 
On the front or back of the uterine body a generally rounded promi- 
nence is detected, resembling the blunt end of a hen's egg, but over- 
hanging the retreating lower uterine segment very distinctly. 2 When 

1 The Editor of this System taught this sisn to the writer long before Hegar's assistants published 
it. Jewett, Therapeutic Gazette, July 15, 1891. 

2 Grandin first insisted on this sign : N. Y. Med. Record, 1886, p. 241. 



DIAGNOSIS OF PREGNANCY. 



141 



in front the profile is that of a full-breasted, corsetted woman bending 
forward. This rounded cornice, or overhanging, may project in any 
direction or in all directions. No change of early pregnancy is more 
constant than this. 

The other form of prominence is lop-sided. A circumscribed portion, 
such as half the uterine body, or one horn, or one side near the cervix, 

Fig. 139. 




Right and left halves of frozen section of uterus at 2% months, showing thin, relaxed walls and 

thick decidua. (PrNARD.) 

is rounded and protruding. The protuberance will constitute the elastic 
portion, cut off by a groove from the flatter, thinner, denser part. 1 

Owing to the presence of Intermittent Contractions the signs 
to be found in a given uterus are subject to some variations. During 

Fig. 140. 



^UM 




Bimanual examination for compressibility of the isthmus at the sixth week. 

relaxation the body of the organ is either soft, compressible, and flat- 
tened, or else doughy. As contraction comes on the body becomes 
elastic to the touch and more globular ; while at the height of the con- 

1 Dickinson pictured this in 1893, in the N. V. Jour. Gyn. and Obst. Braun-Ferwald (Wiener 
klin. Wochenschr., 9 Marz, 1899, and Monatsch. f. Geb. u. Gyn., May, L899), and Piskacek (Wien, 
Braumiiller, 1899, Ucber Asladungen umschxiebenergebarmutter-Abschnitte) have elaborated 
findings. 



142 PHYSIOLOGY OF PREGNANCY. 

traction the whole body is rigid and hard. The change from one of 
these conditions to the other may take place under the finger. (Fig. 138.) 

Elasticity. If the empty uterus were always as hard as a raw 
potato, and the gravid uterus elastic as a rubber ball, a diagnosis of early 
pregnancy would be easy. Unhappily the conditions are not so simple. 
The corpus uteri of gestation, when of typical consistency, is resilient, 
distinctly suggesting "the fluid elasticity of the growing ovum" within. 
In this condition one most frequently finds it, and the finding constitutes 
one of the most easily determined and most valuable of the early signs. 

Density Differences between Right and Left Sides. In a 
certain percentage of uteri of early pregnancy one portion of the body 
is dense, hard, or resisting, and the remainder, usually the larger por- 
tion, is elastic. (Fig. 141.) Between these two parts an upright or 
oblique or crescentic furrow runs as a clean-cut boundary. These 
characters may temporarily disappear during a contraction. 

Fig. 141. 




Front views of uteri six weeks pregnant, showing two common types. 

A. Prominence and elasticity on one side, density toward the other horn, with a furrow between. 
B. Bulging and elasticity symmetrical and anterior. 

Furrow t s or Folds. Grooves, long or short, straight or curved, 
may run across the front or back of the corpus or fundus. A double 
groove will define a fold, and the fold may be hard on top, constituting 
a ridge. Folds and grooves run longitudinally or obliquely more often 
than across. 1 

Size. The increase is fairly regular, and may be determined by com- 
parison of findings three weeks apart. Unhappily the finger has not a 
memory of that duration. Increase in length up to the sixth or even 
the eighth week is very difficult to estimate. But with the increase in 
thickness it is different, since the antero-posterior dimension of the 
corpus is readily palpated, and expansion is appreciable at the sixth or 
eighth week, as the body then measures 2 inches (5 cm.) from front to 
back. At the end of the third month the organ is 5 inches (12.5 cm.) in 
length, 4 inches wide (11 cm.), and 3 inches thick (8 cm.) ; that is, about 
the size of a man's fist tightly closed. 

1 Dickinson (N. Y. Jour. Gvn. and Obst., June, 1892), confirmed by Hegar (Deutsche med. Woch- 
ensohr., 1895. No. 35). 



DIAGNOSIS OF PREGNANCY. 143 

The date of appearance of the signs that are determined by conjoined 
manipulation is the sixth week on an average ; but practice enables one 
to find them in favorable cases as early as the third or fourth. At the 
eighth week they ought to be distinct. Later the ovum fills the cavity 
more and more completely, and compressibility is lost after the third 
month. The asymmetries of growth and density may persist to the 
fifth month. 

Softening of the Cervix. After the first month the consistency of 
the cervix changes. First a velvety feel like that of the mucous lining 
of the cheek is noted, covering the hard knob beneath. The softening 
progresses upward rather slowly until the sixth month. At the eighth 
month the whole cervix has become yielding, so that the finger passes 
through the canal without resistance. Indeed, at term there seems to be 
no projection, the cervix having the same consistency as the vaginal wall. 

"A similar softening occurring from pathological causes lacks the same 
progressive character." Conversely, a hard cervix and especially a 
small firm cerv r ix rules out a supposed late pregnancy, and thus, in the 
differential diagnosis of obscure abdominal tumors, becomes a factor of 
no mean value. 

The Possibilities of Error connected with the early signs are as 
follows : 

In the non-gravid or virgin uterus somewhat similar conditions may 
be found by skilled touch when a complete examination is rendered easy 
by an abdominal wall that is thin and relaxed in a patient free from 
sensitiveness. Considered in profile, the anterior surface of the virgin 
uterus is approximately flat or slightly rounded, whereas the posterior 
face shows a distinct convexity. During the intermittent contractions 
that can be appreciated by palpation in many uteri in the unimpregnated 
state a more globular form and a hardening of the whole uterine body 
develop, the antero-posterior diameters especially increasing. 1 These 
vacillations in consistency have, however, but a short range, elasticity 
and bogginess of the body being infrequent, and thinning at the lower 
segment absent (except in some anteflexions). Asymmetry, or partial 
■division of the corpus into sections or chambers by a palpable furrow, 
or into ridges, while it is not uncommon in the non-parous uterus, pre- 
sents no striking contrast of consistency between the right and left sides. 
Softness of the cervix due to oedema alone, or the dusky hue due to erotic 
feeling, are not accompanied by some of the other pregnancy signs. 

Anteflexion with atrophy of the junction of cervix and body will 
yield the hour-glass isthmus with a body rounding out above the thinned 
-angle. Here the smallness of the body, together with its hardness, must 
exclude pregnancy, as well as the lack of increase in size or elasticity 
proved by an examination two or three weeks later. Hyperemia, 
hyperplasia, or subinvolution will exhibit an enlarged body ; but the 
history and symptoms of chronic uterine disease, the resistance to the 
touch, and the absence of Hegar's sign, in conjunction with the station- 
ary character of the findings, will exclude pregnancy. Retroversion 
with flexion will present swollen conditions resembling the alterations 
of pregnancy. Reposition — and consequent shrinkage — may be neces- 

1 Lindblom, Archiv f. Gyn., Jan., 1892 ; Acconci, Turin, 1881, epitome in Centralblatt f. Gyn., 

1S92, No. 8. 



144 



PHYSIOLOGY OF PREGNANCY. 



sary before the diagnosis can be settled. A soft submucous fibroid causes 
hemorrhage rather than amenorrhea. 

Internal Ballottement. One or two fingers against the anterior vaginal 
wall close to the cervix give a sudden impulse to that part of the foetus 
resting against the anterior uterine wall. The child floats up through 
the liquor amnii. and after a slight and momentary excursion settles back 
against the finger-tips, repercussing with a very gentle tap. The depart- 
ure alone, without evident return, is enough to constitute this sign. In 
order to develop it the long axis of the uterus should be vertical, and 
this is brought about by a posture half-way between sitting and lying 
down, on the edge of a bed or table. 

The value of the sign is very great, but there are others that develop 
much earlier that are of greater import. It is detected when the child 
is large enough to impart sensation to the finger, and ceases when the 
bulk of the foetus too nearly fills the cavity, being present, then, during 
the fifth and sixth months (twenty-one to twenty-six weeks). The foetus 
is too light before this time, and there is too little fluid later. Bal- - 
lottement is absent with scanty liquor amnii, with twins, and with the 
placenta low in front. 

The possible but infrequent fallacies in ballottement are an anteflexed 
uterus, a pedunculated cyst or fibroid, internal projections of large cysts, 
vesical calculus with the bladder full, a kidney floating low, pulsation 
of the uterine artery (Jewett). 

Fig. 142. 



\ 




~im*^ y 



r 



Internal ballottement, semi-recumbent posture, at sixth month. 



Foetal parts may be felt through the vaginal and uterine walls by 
the twentieth week (fifth month, or earlier); the head or breech made 
out by the twenty-eighth week (six and one-half calendar months), and 
reached directly through the cervix during the seventh month (Winckel). 



DIAGNOSIS OF PREGNANCY. 



Uo 



10 
11 

12 

IS 

14 

15 
16 
17 

18 
19 
20 

21 
22 
23 
24 
257" 

26 I 

— 7 
27_ 

28 

29 

30 

— 8 
31 

32 

33 

34 

— 9 
35 

36 

37 

10 






PKEGXAJVCY-THE signs by months. 



3^ qS History. 



Mammary. 



G 



9 



Suppression 
of menses 

(throughout). 



Nausea. 



Size -nodules. 
Veins. 
Primary areola, 

pigment, follicles, 
corrugation. 



Nausea. 



Nausea passes. 



Quickening 

(4% months). 



All, throughout 
pregnancy. 

Milk. 



Secondary 
areola. 



All, throughout. 



Abdominal. 



Fundus rises. 



Foetal shock. 



Pigmentation. 
Intermittent 
contractions. 

Fcetal parts. 
Fcetal heart. 
Uterine souffle 

Funic sou file . 



Fcetal move- 
ments. 

External 
ballottement. 

Fundus at navel. 
Striae. 



All, throughout. 



Pelvic. 



Uterine body 
bulging,— elastic 
or doughy ; 
isthmus 
compressible ; 
cervix softening. 



As before. 



Purplish hue. 



Cervix softens 
progressively. 

Compressibility lost. 
Fcetal parts. 



Internal 
ballottement. 



Internal 
ballottement. 



Ballottement lost. 
Cervix patulous, 
pulpy. 



10 



146 PHYSIOLOGY OF PREGNANCY. 



DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 

In the early months : 

Anteflexion of the uterus with atrophy of the angle and hyperemia of 
the body may closely counterfeit the organ six weeks pregnant. The 
peculiar elasticity of the corpus uteri and its ready variations from relax- 
ation to firm contraction are missing, while the persistence of menstrua- 
tion, even though scanty, as well as the stationary character of the 
findings, as shown at a later examination, will make the distinction. 

A pedunculated fibroid of the anterior uterine wall is solid, and, there- 
fore, unlike the corpus of pregnancy in consistency. 

An ovarian cyst or a distended tube in the cul-de-sac may suggest retro- 
version of a gravid uterus, especially if moving with the cervix. Their 
tension and clear elasticity are stable, and more marked than those of 
the ovum-filled corpus. 

Chronic metritis and subinvolution, on the other hand, impart to the 
finger a firmer resistance, and not a globular shape nor bellying in the 
antero-posterior diameter, nor do they show compressibility of the isthmus. 

In retroflexion the swollen uterus may resemble the gravid organ of 
the fifth or sixth week, and not until after reposition and shrinkage may 
the difference be apparent. 

The diagnosis of tubal gestation is fully treated of in the chapter on 
Ectopic Gestation. 

In all these conditions experience, expertness, and access to all parts 
of the pelvis in order to map out the organs may, possibly, be necessary 
for a diagnosis. A dubious history, and sensitiveness, and resistance 
may call for repeated examinations or for anaesthesia. One mistake in 
five, or many blanks, are conclusions to be expected. 

In the later months : 

General Rule in Differentiating. Three discrepancies are always to be 
borne in mind as pointing to conditions other than pregnancy: 

1. The rate of enlargement differs from that of the pregnant uterus. 

2. The size and the period of amenorrhea do not correspond with 
each other. 

3. The most important signs of pregnancy are absent, namely, foetal 
heart, foetal movements, distinctive foetal parts, and the external and 
internal ballottement. Menstruation usually persists. With each of 
the following disorders it will not, therefore, be necessary to reiterate the 
above statements. 

Fat. The general rotundity of the patient arouses suspicion, while 
locally the thickness of the deposit may be estimated by lifting a fold or 
seizing the bulk of the belly-wall between the hands. The whole sur- 
face is faintly resonant on percussion. A bdomino- vaginal exploration 
fails to bring an organ between the two hands, through which any thrust 
may be transmitted, and the small, hard cervix gives a clue to the size 
of the uterus. Obesity is a frequent cause of amenorrhoea or scanty 
flow, and especially when anaemia coexists. 

Tympanites. Here the girth is variable from time to time, the reso- 
nance is general and obvious, and a firm tumor is lacking. With steady 
pressure while the patient coughs or breathes deeply, a deeper and deeper 



DIAGNOSIS OF PEEGXAXCY. 147 

reach sinks the hand toward the spinal column. Again, the cervix has 
not softened to tally with the bigness of the abdomen. 

Ascites. The shape is suggestive, being not prominent, but rather flat 
in front and bulging on the sides, as the patient lies. Percussion briugs 
out tympany in front and flatness or dulness at the flanks, the level of 
the flatness changing with changes of posture. In pregnancy it is a 
curiosity to find any intestinal coils in front of the uterus when the fun- 
dus has ouce risen well out of the pelvis. Suppression of the menses is 
often seen in dropsy, and the history of disease of the heart, kidney, or 
liver will indicate the cause. 

Ovarian Cyst. In its earlier stages the resistance is most marked at 
one side of the median line; later it may be central, but this will be after 
long growth; a monocyst is more smooth, globular, and elastic than the 
uterus, and fluctuates all over. The most important point lies in the 
characteristic cyst-sensation imparted to the hands. The uterus, and with 
it the cervix, is displaced toward the back, side, or to the front, as a 
finger, following upward from the small, firm external os may be able to 
ascertain, though the distinction is often most difficult. In the presence 
of a moderately long pedicle there may be a space between uterus and 
cyst into which the lingers can press. The gravid organ of the fourth 
month, rotund, firm, without movements, foetal parts, or heart-sounds, 
and with the cervix far back, where it cannot easily be traced as a con- 
nection of the mass above, most nearly resembles a cyst which has 
crowded the womb backward. But the cervix of pregnancy at this stage 
is boggy on its surface, is usually to be found in the median line, and 
may be followed up laterally into the body. This body and its changes 
in consistence are to be studied, the round ligaments located, if possible, 
and notes made for comparison three or four weeks later. The tension 
of hydramnion is suggestive of a cyst. Cyst and gestation may exist 
together and render the diagnosis difficult. Amenorrhoea is not often 
present in ovarian growths, and the patient has commonly a history of 
increasing dysmenorrhoea. 

Fibroid Tumors. Most growths of this kind are very hard. Some are 
nodular, and occasionally one bears a likeness to foetal parts. Careful 
palpation and bimanual examination must map out the relation between 
the unsoftened cervix and the tumor or tumors in or on the uterus above. 
A study of the location of the round ligaments may demonstrate the 
common asymmetry of enlargement due to fibromata, as compared with 
the usual symmetry of pregnancy. Instead of cessation of menstruation, 
uterine hemorrhage is the rule, either periodic or continuous, and if 
anaemia stops the flow, the arrest is gradual and not sudden. Occasion- 
ally the new r growth is subperitoneal and pedunculated, or the cervix 
may be gaping to give exit to a submucous fibroid. When fibromata and 
pregnancy coexist the tumors grow rapidly, particularly the intramural 
variety, and the combination adds to the difficulty of the diagnosis. 
Unless the tumor is very large and low, the purplish hue of the vagina 
and cervix is not developed in these growths as in pregnancy. In diffi- 
cult cases, again, the final appeal is to time or to chloroform. 

Enlarged Organs. These develop from above downward. The dul- 
ness, the line of the lower edge, and the resonant strip below serve to 
indicate the source of the abdomen's prominence. Encysted dropsy is 



148 PHYSIOLOGY OF PREGNANCY. 

rare. Wandering organs, like the kidney and spleen, can be pushed 
upward. Malignant omental and mesenteric growths are lumpy and 
fixed, presenting, if large, a marked cachexia late in life. 

An over-distended bladder gives a history of short duration, pain, and 
dribbling. Retroversion, with or without pregnancy, is often its asso- 
ciate. The catheter settles the diagnosis. 

Phantom, Tumor. In spurious pregnancy, breast changes, the size of 
the abdomen enlarged with gas and fat, and the imaginary movements 
have led hysterical and anaemic individuals and women near the meno- 
pause or excessively anxious for children into curious errors. The uterus 
is found to be small, and chloroform may be needed to assure the family 
of the self-deception. 

Hozmatometra. A growth characterized by monthly increase in size, 
accompanied with severe pains and contractions before the appearance 
of menstruation at puberty, points to an atresia somewhere between the 
hymen and cervix. It is very rare. More rarely still the canal may 
have closed up from injury or disease. 



CHAPTEE V. 

DUKATION OF PREGNANCY.— EVIDENCE OF PREVIOUS 
PREGNANCY. 

The Duration of Pregnancy. 

~No definite statement can be made of the typical normal length of 
the period of gestation. Variations in the apparent duration of preg- 
nancy occur in animals, in which calculations have been made from the 
date of a single coitus. When impregnation occurs in the human 
female after a single coitus, the date of which has been accurately 
known, as in single women, or in married women whose husbands have 
been absent for months, the average period between the fruitful congress 
and labor is two hundred and seventy-three days. But calculations can 
rarely be based on a single coitus. Even when it is possible to compute 
from one coitus, the period intervening between the fruitful coitus and 
labor varies in different women, and in the same woman in different 
pregnancies. This is explained by several possible causes. The inter- 
val between insemination and fertilization is not constant. We have no 
exact knowledge of the length of time during which the respective 
sexual elements, the ova and the spermatozoa, may retain their vitality 
in the maternal passages. From the data at present known, it is 
assumed that the time of fecundation may vary from a few days to a 
week or more after insemination. Again, gestation may be prolonged 
beyond the usual normal period, or may fall short of it. The precise 
duration of pregnancy cannot, therefore, be definitely determined. 

Should impregnation occur within the first few days following the men- 
strual period, the catamenial flow is almost certain to be absent at the 
next menstrual date; when impregnation takes place shortly before an 
expected period, a partial menstruation may follow at the menstrual 
epoch, but more or less atypical in character. The probable date of 
labor as computed from the last menses becomes still more uncertain in 
women whose history is one of menstrual irregularity. 

Whether or not a woman can give birth to a child ten months or more 
after the last coitus is a medico-legal question on which the obstetrician 
may be called upon to testify. The French law recognizes the legitimacy 
of the offspring when the apparent term of gestation is within 300 days. 
In Austria the recognized duration of pregnancy is from 240 to 307 
days. In England and the United States there are no legal limits, but 
the possible protraction of gestation is admitted by all legal authority. 
Taylor and Beck, in their works on IfedicalJurisprudence, cite numerous 
instances of protracted gestation. Several cases are recorded by obstet- 
ric writers in which pregnancy was believed to have continued 319, 
324, 332, and 336 days respectively after the last menstruation. Dewees 
cites a case which continued for ten calendar months. Playfair, Lusk, 
and Leishman have all mentioned instances of considerable prolongation. 

(149) ^ 



150 PHYSIOLOGY OF PREGNANCY. 

Most frequently in such instances the child is a male and of large size. 
Some women appear always to exceed the usual limits of pregnancy. 

Prediction of the Date of Labor. 

(a) Naegele's Rule for the prediction of the date of labor is based 
upon the fact that the average interval between the beginning of the last 
menstruation and the occurrence of labor is two hundred and eighty 
days. It consists in counting forward nine calendar months from the 
beginning of the last menstruation and adding seven days. This is a 
ready method of computing approximately two hundred and eighty days 
from the beginning of the last menstrual period. The same result is 
gained by counting backward three months and then adding seven days. 
The prediction is usually accurate within a week. An error of two or 
three weeks, however, is possible, since in exceptional instances preg- 
nancy may begin at any period between the menstrual epochs. 

(6) Reckoning from the Date of Quickening. It is a common popular 
custom to estimate the date of parturition from the time of quick- 
ening, counting this sign as occurring in mid-pregnancy. But as the 
period of quickening varies from the twelfth to the twentieth week, and 
the observations of the patient are always liable to error, the method is 
obviously unreliable. When, however, accurate menstrual data are not 
available, or when pregnancy has occurred in the absence or temporary 
suspension of the menstrual function, reckoning from the period of 
quickening may serve for an approximate estimate. 

(c) Mensuration of the Uterus is not wholly reliable for this purpose, 
since the amount of liquor amnii varies in different cases, and the 
size of the foetus is not always the same in different instances for the 
same period of gestation. Moreover, more than one foetus may be 
present. The situation of the fundus cannot be depended upon for 
determining the stage of gestation, for the reasons just stated under men- 
suration of the uterus. The height of the fundus, too, is influenced by 
the tonicity of the abdominal walls, by the capacity of the pelvis, and 
by the direction of the uterine axis. Again, in comparing the situation 
of the fundus with that of the umbilicus, it must be remembered that 
the umbilicus is not altogether a fixed point. 

(e) Mensuration of the Foetus. The length of the foetus is about double 
that of the foetal ovoid. The length of the foetal ellipsoid may be 
measured with approximate accuracy through the abdominal wall, by 
placing the poles of a pelvimeter on the abdominal wall, one opposite 
each extremity of the foetal ovoid. The measurement may be taken 
more accurately by placing one pole of the pelvimeter on the abdomen 
over the upper extremity of the foetal mass and passing the other pole 
through the cervix and holding it against the presenting part; but this 
method is obviously objectionable and should be reserved for emergencies. 
The rate of foetal development, however, is not uniform. Nevertheless, 
measurements of the foetus, including the accessible diameter of the 
head, afford fairly reliable data for predicting the date of labor. 

The approximate lengths of the foetus in the last four months of 
intra-uterine development respectively are stated in the following 
table : 



DURATION OF PREGNANCY. 151 



Length of the Fcetus. 



Sixth calendar month, 30 to 35 cm., about 12 to 14 inches. 
Seventh calendar month, 35 to 40 cm., about 14 to 16 inches. 
Eighth calendar month, 40 to 45 cm., about 16 to 18 inches. 
Ninth calendar month, 45 to 50 cm., about 18 to 20 inches. 

Evidence of Previous Pregnancy. 

Evidence of a previous pregnancy which had occurred at any remote 
period, and which had continued but a few months is difficult or impos- 
sible of recognition. Within a few days following the expulsion of its 
contents, the uterus will be found more or less enlarged and the cervix 
more than normally open. It may be difficult of distinction, however, 
from an enlarged and menstruating uterus. Soon after an abortion rem- 
nants of the foetal structures may be looked for — microscopically — in the 
products of a curettage or in the lochial discharge. 

The physical evidences of a previous pregnancy are much more dis- 
tinctly marked after recent parturition at or near term. The fundus 
uteri will then be found in the hypogastric region, much enlarged, and 
the cervix will be patulous. For several days after labor the genital 
discharge corresponds in quantity and character to the lochial flow. 
Fresh lacerations of the cervix may be detected. The vaginal portion 
of the cervix is more nearly cylindrical in the parous than in the nullip- 
arous woman, and its lower border is more or less deeply notched. 
Relaxation of the vagina persists for some time after delivery. The 
fourchette is usually, and the hymen is always, destroyed in the first 
labor. 

The abdominal walls are soft and relaxed, with the skin thrown into 
folds, and its lower half is marked with white, shining lines (linece albi- 
cantes). 

The breasts are tumid and contain lacteal secretion. The presence 
of colostrum corpuscles in the breast secretion indicates a recent delivery. 
The characteristic areolae of pregnancy are in great degree permanent, 
and they afford, therefore, no diagnostic evidence. On the faces of preg- 
nant women frequently there may be seen the chloasma uterinum, which 
sometimes lasts years after parturition. Menstrual and uterine disor- 
ders, however, may cause the same skin affection in women who have 
never been pregnant. 

The general appearance of the woman, even after recent delivery, 
usually presents nothing characteristic. 

After death the recognition of the parous condition is not difficult. 
The cervical canal has lost its fusiform shape; the uterus is enlarged 
and heavier; the corporeal cavity is approximately oval, the inner sur- 
face of the fundus uteri being no longer convex, as in nulliparae, but flat 
or even concave. 



CHAPTEE VI. 

HYGIENE AND MANAGEMENT OF PREGNANCY. 

It is the duty of the practitioner of medicine engaged to attend a 
woman in confinement to give her such hygienic instruction as she may 
require and to extend a certain degree of professional attention through- 
out pregnancy. Many disorders and complications are likely to arise 
during gestation, and the woman's welfare may depend in no small 
degree upon the watchful care of her medical adviser. 

Diet. Early in pregnancy some degree of digestive disturbance and loss 
of appetite is the rule. By the fourth month the gastric irritability usually 
begins to abate and appetite and digestion improve. In the regulation of 
diet reasonable regard should be had for the preferences of the patient. 
Individual fancies, dislikes, or idiosyncrasies must be consulted. In 
this way the morning sickness may sometimes be managed satisfactorily. 
By taking digestible light nourishment between meals one may often 
control the nausea due to the emptiness brought about by rapid absorp- 
tion to meet the increased demand. Most foods, animal and vegetable, 
which are nutritious and easily digestible, are suitable. In short, the 
diet during pregnancy should be plain, simple, digestible, highly nutri- 
tious, and be taken at regular intervals. No invariable rule can be laid 
down for all cases, as the same foods do not agree equally well with all 
patients. A sufficiently liberal diet contributes to improve hamiatosis, 
increases functional activity, augments body-weight, gives a healthy 
tone to the bloodvessels and tissues, and diminishes the susceptibility of 
the nervous system to pain and to reflex irritation. A suitable diet, too, 
during pregnancy is obviously essential to the normal development of 
the foetus in utero. 

Excessive eating, on the other hand, must be avoided. The toxaemia 
of pregnancy is often the result of overfeeding. Especially in the later 
weeks of pregnancy, when the gravid uterus exercises pressure upon the 
stomach, food should be taken in small quantities. Too liberal diet at 
this time may result in overdevelopment of the foetus. Per contra, a 
restricted diet during the last six weeks of pregnancy, with limitation of 
sugars and of starchy foods, it is claimed tends to lessen the size and 
hardness of the child's head and to facilitate the birth (Prochownik). 

The subject of digestive disturbances is fully treated on page 387. 

Digestive Organs. Usually some attention "must be directed to the 
stomach disturbances. Allusion has already been made to their dietetic 
management, which is often more efficacious than medicinal treatment. 
In feeble digestion good results may be expected from the temporary 
use of koumyss or predigested foods. When the stomach rejects all 
food resort must be had to rectal alimentation. 

It is important that the bowels be evacuated at least once daily. 
Most women are habitually constipated, and pregnancy commonly aggra- 



HYGIEXE AND MANAGEMENT OF PREGNANCY. 153 

vates the disorder and intensifies the ill results accruing from incom- 
plete intestinal elimination. 

The use of fruits, fresh vegetables, and coarse bread will often accom- 
plish much in relieving constipation. The mineral waters, saline or 
sulpho-saline, solutions of sodium phosphate or Carlsbad salts answer 
admirably. Other efficient laxatives are aloin, podophyllin, and cascara 
sagrada. Rectal enemata should be avoided, and drastic cathartics are 
always objectionable, owing to the danger of causing abortion. Instances 
are rare in which purgation is necessary. 

Exercise. Moderate muscular exertion, as a rule, is well borne. Daily 
walks in the open air are useful both for exercise and recreation. Sea- 
bathing is permissible if properly managed. Most other forms of light 
and agreeable exercise are beneficial. Cycling may usually be permitted, 
if practised in moderation and with care to guard against accident. 
Passive exercise will be found highly salutary to those who cannot bear 
the more active forms. Carriage-riding affords the necessary fresh air 
and sunlight. Horseback-riding, carriage-riding over rough roads, lift- 
ing, and all violent muscular strain and overwork must be prohibited. 
Crowded and ill-ventilated rooms should be shunned. 

Properly regulated physical exercise is not only essential to the 
normal progress of gestation, but it doubtless conduces to easy labor. 
It is especially important in women of delicate health and feeble mus- 
cular development. 

Rest. The pregnant woman requires an abundance of sleep. Eight 
hours daily of undisturbed sleep are essential. An hour or two immedi- 
ately preceding the noon meal may well be added to the usual night's 
rest. 

Clothing. The clothing should be so adjusted as not to exercise 
undue pressure upon the chest and abdomen. Corsets must be pro- 
scribed. Garments suspended around the waist should be as light as is 
consistent with comfort and health. The heavier clothing should hang 
from the shoulders. Pressure upon the abdomen impeding the ex- 
pansion of the growing uterus and its contents, favors the develop- 
ment of a not uncommon complication of pregnancy — albuminuria and 
uraemia. In multipara? with lax abdominal walls, relief is often afforded 
by supporting the lower abdomen with a properly constructed abdominal 
belt. Such an appliance must be adjusted with care not to increase the 
pressure upon the pelvic and renal veins. It should exert a lifting 
rather than a constricting pressure. 

Bathing. The functions of the skin should be kept active by fre- 
quent bathing during the entire course of pregnancy, and particularly 
in the later months, when it is important to relieve the kidneys as much 
as possible of the extra work thrown upon them. Daily baths are advo- 
cated, at a temperature suitable to the time of year and the habits of the 
individual, although it is, perhaps, preferable that the bath be warm at 
first, and rapidly cooled at the finish. To secure proper reaction the 
skin should be rubbed briskly with a coarse towel. 

Breasts and Nipples. Attention should be given to the breasts and 
nipples preparatory to lactation and nursing. If they are retracted the 
patient should be taught to draw them out gently with the thumb 
and finger, for a few minutes daily, particularly during the last few 



154 PHYSIOLOGY OF PREGNANCY. 

months of pregnancy. This not only serves te develop them, but it 
accustoms them to manipulation and lessens the danger of injury by 
nursing. "When a nipple is inverted or deeply creviced the smallest 
size of cupping-glass topped with a rubber bulb, or a breast-pump, 
applied a few minutes each day, serves to roll out the depressions, and 
by toughening the thin epithelial layers at the bottom to prevent fissure 
and infection when nursing begins. Strict cleanliness is essential. Daily 
ablutions with cold water are recommended as a prophylactic against 
fissures during nursing. , Daily inunctions with fresh cacao-butter are 
better than the astringent lotions commonly employed. Friction with 
gauze to remove the ointment renders thin-skinned nipples less sensitive. 

Hygiene of the Pelvic Organs. Vaginal injections are not necessary, 
except in the presence of a leucorrhoeal discharge. If injections are 
required a saturated solution of boric acid, one or two quarts, may be 
given with a fountain syringe and with the least possible mechanical 
violence. The temperature should be that of the body. 

Local treatment to a diseased vagina, cervix, and canal may, with 
proper precautions, be carried out during pregnancy. Pregnancy always 
aggravates an existing chronic cervical endometritis; it increases the 
cervical catarrh, the granular degeneration, the secondary vaginitis, and 
vulvar pruritus. The gentle use of warm vaginal injections and topical 
applications of mild astringents and emollients, and, in rare cases, of 
solutions of silver nitrate, may not only improve the local condition, 
but also aid in controlling reflex disturbances, such as nausea and 
vomiting. 

Sexual Intercourse should be restricted ; it is injurious to some preg- 
nant women. Total abstention should be enjoined at the menstrual 
dates, and especially in women who have previously aborted. It is 
most likely to be harmful in the early months of pregnancy and again 
toward the close. 

The usual marital relations are distasteful to most women at this 
time, and to many are the source of much pelvic discomfort, as well as 
a prominent factor in aggravating the nausea of pregnancy and in the 
induction of abortion. 

Urinary Excretion. It is especially important that careful attention 
be directed to the performance of the renal function. A chemical and 
microscopical examination of the urine should be made at least twice 
monthly during the earlier months and not less than once weekly during 
the last three months of pregnancy. Close observation of and the care- 
ful regulation of the function of the kidneys during gestation are of the 
utmost importance in the prophylaxis of the toxaemias of pregnancy. 
The changes liable to occur in the urine of pregnant women have been 
described in another chapter. 

The occurrence of albuminuria should always be regarded with 
suspicion. Albuminuria always calls for the institution of diet and 
other remedial measures. 

The most valuable evidence of the emunctory activity of the kidneys 
is the total daily quantity of urinary solids, especially of urea. The 
total output of urinary solids daily is normally about 1000 grains, and 
of urea 500 grains. These figures, however, are subject to consider- 
able variation within physiological limits. They are affected by the 



HYGIENE AND MANAGEMENT OF PREGNANCY. 155 

quantity and quality of food ingested and by the degree of muscular 
exertion. 

The patient should be directed to bring a sample of urine twice a 
month, to measure an average day's total, and to give notice if it falls 
below the quantity proper for her weight and the season. Note should 
be taken frequently not only of the daily quantity of urine passed, but 
also of its specific gravity. Samples for examination should be had from 
the entire amount of urine voided during the twenty-four hours. The 
total daily solids may be estimated approximately by the following 
method : Multiply the last two figures of the number representing the 
specific gravity by the number of ounces for the day. The product 
multiplied by ly 1 ^ indicates nearly the number of grains of solid matter 
in the given number of ounces. 

The quantitative determination of urea is best conducted by Bartley's 
method, as detailed on p. 212. 

The Mental Condition of a pregnant woman should always be an object 
of solicitude. With increased emotional susceptibility she may be quite 
excitable, irritable, and be easily disturbed by external influences which 
in the non-pregnant would make no injurious impression. 

It is an interesting question to what extent the unborn child is affected 
by the mental condition of the mother. There is no doubt that her 
mental state may be the cause of modifications in the physical, the in- 
tellectual, and the moral characteristics of her offspring. The mental 
hygiene of the mother is, therefore, important. She should be guarded 
from all untoward influences. Kind assurances are helpful, and judicious 
amusement should be encouraged. Associations should be agreeable, 
cheerful. A gentle protective care is to be thrown around the patient, 
and she should be treated with considerate kindness. In the attainment 
of this desirable environment the co-operation of the friends is obviously 
essential. 

Infectious Exposures. The pregnant woman should be warned of the 
danger that mav come from contact with infectious or contagious dis- 
ease. Such exposures are doubly dangerous shortly before labor. While 
pregnancy continues the natural resistance to the specific action of 
pathogenic germs is undoubtedly increased, but after parturition the 
exhaustion of labor tends to diminish resistance, and the woman becomes 
an easier prey to infection. The diseases with which it is most danger- 
ous for her to come in contact are scarlet fever, diphtheria, erysipelas, 
and all septic conditions. 

Avoidance of Drugs. In all cases as little medicine as possible should 
be administered. Pregnancy as a purely physiological condition is best 
managed by a close observance of judicious hygienic rules. 

Obstetric' Examination. After the foetus is viable it is the duty of 
the obstetrician to make careful examination by the abdomen. In all 
cases an external and generally an internal examination should be made 
toward the last month of pregnancy. The objects of this examination 
are to determine : 

1. Whether or not the woman is actually pregnant. 

2. The duration of pregnancy. 

iThe proper observance of rules of hygiene during pregnancy may be better insured by placing 
in the hands of the patient a pamphlet or convenient manual briefly setting forth her duties in 

the matter. 



156 PHYSIOLOGY OF PREGNANCY. 

3. Whether the pregnancy is single or multiple. 

4. Whether the foetus is living. 

5. The presentation and position of the foetus. 

6. The measurements of the maternal pelvis. 

7. The size and hardness of the foetal head. 

8. The possible existence of pelvic or abdominal tumors and of other 
pathological conditions that may injuriously affect the labor. 

9. The probable date of labor. 

10. The obstetric prognosis. 

In first pregnancies the vaginal examination also determines small 
size, spasm or rigidity of the vulva ; in pluriparse, old injuries and a 
possible low seat of the placenta are to be borne in mind. 

The precise methods of diagnosis which are carried out in well- 
managed maternities ought also to be the rule in private practice. 
Should the conditions be such as may lead to long and difficult labor, 
the obstetrician should be forewarned, that he may determine in ad- 
vance what course to pursue: whether to choose the induction of prema- 
ture labor, to wait till term and depend upon the use of forceps, to 
resort to podalic version, or symphysiotomy, or a Csesarean section. The 
knowledge gained by the proper study of the obstetric case in ad- 
vance of labor affords the means of saving many maternal and foetal 
lives. 

The obstetric examination will be treated more in detail in connection 
with the management of labor. 



PAET III. 

PHYSIOLOGY OF LABOR. 



CHAPTER VII. 

THE MECHANICAL ELEMENTS OF LABOE. 

Three factors are concerned in the mechanism of labor. They are : 
1. The Expelling Powers. 2. The Passages. 3. The Passenger. An 
intimate knowledge of these elements of the parturient process is the 
first essential to a proper understanding of the course and management 
of both normal and abnormal labors. 

I. The Expelling Powers. 

The expellent forces are three : a. The contractions of the uterus. 
b. The action of the abdominal muscles, c. The action of the pelvic floor. 

(a) The Uterine Contractions. The chief expelling power is the con- 
traction of the muscular walls of the body of the uterus, or, rather, of 
the upper uterine segment. 

The uterine contractions are involuntary, being mainly under control 
of the sympathetic nervous system. Yet, though independent of the 
will, they may be strengthened, enfeebled, or wholly arrested by emo- 
tional influences. The uterus has two motor centres, one in the medulla 
oblongata and one in the lumbar portion of the cord; apart from these 
its contractions are influenced to some extent by the action of its own 
ganglia. Routh observes that direct communication with the brain 
is not essential to co-ordinate uterine action, though the brain seems 
to regulate the pains. Direct communication between the uterus and 
the lumbar enlargement of the cord is probably essential to co-ordinate 
contraction. 

The contractions are assumed to be peristaltic, the wave beginning at 
the fundus, or at the cornua, and sweeping almost instantaneously over 
the contractile segment. This peristaltic character of the uterine con- 
traction is marked in the tubular uterus of some of the lower animals, 
but is inappreciable in the human species. 

They are also intermittent. At the beginning of labor they recur at 
intervals of about thirty minutes. The intervals shorten as labor pro- 
gresses, and at the acme of expulsion they do not usually exceed two or 
three minutes ; frequently at the close of the perineal stage they are 
practically continuous. 

( 157 ) 



158 PHYSIOLOGY OF LABOR. 

The duration of the contraction is about thirty seconds at the onset of 
labor, and it is gradually lengthened to sixty seconds, or. even more, as 
the expulsive efforts reach their height. Variations in both the fre- 
quency and the length of the contraction, however, are subject to some 
degree of irregularity. The event presents three stages, Contraction, 
Persistent contraction, Relaxation. 

The Strength of the Uterine Contraction varies in different 
women. It differs somewhat in the same person at different stages in 
the progress of labor. Frequently it is observed that each alternate 
contraction is more powerful than the preceding. 

The force of the contraction cannot be definitely stated, According 
to Duncan, the combined power of the uterine and abdominal muscles 
may attain a maximum of fifty, or even eighty, pounds; according to 
Schatz it ranges from seventeen to fifty-five pounds. Poppel, Poullet, 
and Ribemont have reached conclusions nearly similar to those of Schatz. 
The estimates of Duncan, Poppel, and Ribemont are based on the 
force required to rupture the membranes. Schatz measured the down- 
ward pressure exerted during a labor pain by means of a species of 
manometer, but the latter method determines only the force with which 
the head moves, while the propelling power obviously must equal the 
sum of the motion and the resistance. Unfortunately, the tocometric 
methods thus far employed are not wholly reliable. Though we have no 
means of knowing the exact value of a labor pain, it probably never 
exceeds and seldom attains the maximum limit above stated. 

Changes in the Shape and Position of the Uterus. During 
a contraction the uterus assumes approximately a cylindrical form, its 
longitudinal and antero-posterior diameters being increased, while its 
transverse is diminished. In other words, its cross-section takes on a 
more nearly circular shape. The fundus is held forward against the 
abdominal wall, and the entire organ is forced downward. The long 
axis of the uterus is brought in line with that of the pelvic inlet. The 
capacity of the upper or contractile segment is diminished, that of the 
lower or passive segment is correspondingly increased. The peritoneal 
covering adapts itself to the changing shape and size of the uterus by 
reason of its elasticity. The muscular structures of all the uterine 
ligaments doubtless contract simultaneously with those of the organ 
itself, and to some extent they assist in the expulsion of its contents as 
well as in fixing the uterus. 

(b) The Action of the Abdominal Muscles. The uterine contractions alone 
are concerned in the dilatation of the lower segment of the uterus which 
takes place in preparation for the expulsion of the foetus. Dilatation 
complete, the action of the uterus is reinforced by that of the abdominal 
walls. At the height of the uterine contraction the woman holds her 
breath, the diaphragm is fixed, and the intra-abdominal pressure is 
increased by the contractile power of the abdominal muscles. This adds 
materially to the expelling force, compressing the active portion of the 
uterus on all sides. The extruding force of the uterine contraction is sup- 
plemented by the general intra-abdominal pressure, and the contents of 
the organ are impelled in the direction of least resistance, downward 
through the expanded cervix. 

Yet the action of the abdominal muscles is not in all cases an essen- 



THE MECHANICAL ELEMENTS OF LABOR. 



159 



tial factor in labor. It is well known that the nterus may expel its 
contents unaided by the accessory powers. This is exemplified in para- 
plegic women and in spontaneous deliveries under anaesthesia. 

Ordinarily the contractions of the abdominal muscles are under control 
of the will. Toward the close of the second stage, owing to the reflex 
effect of painful distention of the passages, they become more or less 
involuntary in character. 

(c) The Action of the Pelvic Floor. The resistance of the pelvic floor 
acts in some degree as an obstacle to the progress of the birth until the 
head is on the eve of expuls'ou. From this time the muscular tonicity 
of the posterior portion of the floor helps to impel the head forward in 
the direction of the outlet of the soft parts. The same force, too, aids 
in the expulsion from the vagina of the after-coming pole of the foetus 
and in the extrusion of the placenta. 

II. The Passages. 

Obstetric Anatomy of the Bony Pelvis. 

The pelvis is the strong bony basin which forms the most important 
part of the birth-canal. (Fig. 143.) The term is derived from the 
Greek word tts/.'C, a bowl. The pelvic canal is irregularly funnel- 



FIG. 143. 




The female pelvis. 



shaped and somewhat flattened from before backward, its larger end 
looking upward and forward, its smaller downward and backward, in 
the erect position of the woman. In it are contained the essential organs 
of generation, and through it the child is expelled in the course of labor. 
Upon its relation to the size and shape of the foetal mass depend the more 
important mechanical phenomena of childbirth. An intimate knowledge 



160 



PHYSIOLOGY OF LABOR. 



of the pelvis, as related to the mechanism of labor, affords the "key to 
the obstetric art." 

The Constituent Parts of the Pelvis are: the sacrum, the coccyx, and the 
two ossa innominata. Each of these bones, though made up of separate 
segments in infancy, is, with the exception of the coccyx, practically one 
in the child-bearing woman. 

The Pelvic Joints. Of obstetric importance are the pelvic articulations. 
They are the sacro-iliac joints, the sacro-coccygeal joint, and the symphysis 
pubis. 

The Sacro-iliac Joixts. In these joints each articular surface is 
invested with a thin plate of cartilage. Small interspaces containing a 
fluid resembling synovia are usually observed between the cartilages, 
especially in women ; rarely these spaces are wholly absent, and even 
when they exist a synovial membrane cannot always be demonstrated. 
In a considerable proportion of cases a true synovial cavity is present 
and the joint is arthrodial in variety. (Browning.) 



Fig. 144. 




Female pelvis, posterior view, showing constituent parts. (Modified from Testut.) 

The ligaments are the anterior sacro-iliac, the posterior sacro-iliac, 
and the interosseous ligament. 

The anterior sacro-iliac ligament is made up of numerous thin and 
comparatively weak ligamentous bands. 

The posterior sacro-iliac ligament is of great strength and importance. 
It consists chiefly of three fasciculi: the two superior run in a nearly 
horizontal direction from bone to bone; the inferior extends obliquely 
downward and inward from the posterior superior spine of the ilium to 
the third and fourth pieces of the sacrum. The latter is the oblique sacro- 
iliac ligament. 

The interosseous ligament consists of separate bands of fibrous tissue 
extending between the articular surfaces. This is not always present. 

The Sacro-coccygeal Joint. This joint has an interosseous fibro- 
cartilage which permits recession of the coccyx. Its ligaments are four, 



THE MECHANICAL ELEMENTS OF LABOR. 



161 



one at each aspect of the joint. The articulations of the coccygeal seg- 
ments usually retain some degree of mobility upon one another during 
the child-bearing period. 

The Symphysis Pubis. The articular surfaces of the pubic bones 
are united by a disk of fibrous tissue and fibro-cartilage. This inter- 
pubic disk is slightly wedge-shaped, being thicker at its anterior than 
its posterior margin, and thicker at the upper than the lower end of the 
joint. A small cavity is frequently present in the interosseous disk ; it 
is produced by absorption of the fibro-cartilage, and is never synovial 
in character. (Browning.) It is oftenest observed in the female. 

There are four pubic ligaments, one on each aspect of the joint. 

The anterior pubic ligament consists of two sets of superficial fibres, 



Fig. 145. 




Os innominatum before fusion of its three constituent parts. (Ribemont-Dessaignes and Lepage.) 
II. Ilium. Is. Ischium. P. Pubis. 



each running obliquely downward across the joint from one pubic 
bone to the other, and of a deep layer which stretches directly across the 
symphysis. The fibres of the latter are blended with the subjacent fibro- 
cartilage. 

The posterior pubic ligament is essentially a layer of thickened perios- 
teum which passes from the posterior surface of one pubic bone to that 
of its companion. 

The superior pubic ligament is a thin bundle of fibres which connects 
the upper aspect of the bones. 

The inferior pubic ligament, the ligamentuni arcuatum, is a stout, 
strong, fibrous bundle arching across from the inferior margin of one 

11 



162 PHYSIOLOGY OF LABOR. 

descending pubic ramus to the other. It blends at the median line with 
the interpubic disk. 

Mobility of the Pelvic Joints. A barely perceptible mobility of the 
pubic bones upon each other is generally present in the last weeks of 
gestation. Experience in symphyseotomy has shown that the sacro-iliac 
articulations are sufficiently movable to permit a separation of the pubic 
bones to the extent of 5 to 7.5 cm., 2 to 3 inches, after section of the 
symphysis, without injury to the anterior ligaments The sacrum, too, 
is capable of rotation in some degree on a transverse axis drawn through 
its base a little below the level of the promontory. Not only is there a 
hinge-like motion at the sacro-coccygeal joint, but the segments of the 
coccyx, as already stated, have some degree of mobility upon one 
another. Owing to the swelling of the interarticular structures which 
obtains in all the pelvic articulations toward the close of pregnancy 
some expansion of the pelvic planes is possible during labor under the 
wedge-like action of the foetal head. 

The False and the True Pelvis. The bony pelvis presents two divisions 
—the false and the true pelvis, or the greater and the lesser pelvis. The 
dividing plane cuts the upper anterior margin of the sacrum, the upper 
end of the symphysis pubis, and the ilio-pectineal line on either side. 
The part above this plane is the false, that below the true, pelvis. 

The false pelvis, together with the vertebral column and the abdominal 
walls, forms a funnel-shaped approach to the true pelvis. The space 
included is a part of the abdominal cavity. 

The true pelvis. It is with the true pelvis that obstetric problems have 
mainly to deal. Here it is that the principal resistance to the birth is 
encountered, and here the more important mechanical phenomena of 
labor are executed. Upon a clear comprehension of the anatomy of 
this part of the pelvis in its relation to the parturient process the skill 
of the obstetrician will largely depend. 

The Brim, Inlet, Superior Strait, Isthmus, or Margin of the True Pelvis. 
The anatomical inlet is located by the upper margin of the sacrum, the 
ilio-pectineal lines, and the upper end of the symphysis. Its outline is 
generally described as approximately heart-shaped. Its contour corre- 
sponds nearly to that formed by two ellipses overlapping anteriorly, 
each of these ellipses representing the engaging sectional plane of the 
foetal head. In exceptional cases the brim is an irregular oval or is 
nearly round in shape. 

Obstetric Landmarks at the Brim. Certain anatomical points about the 
pelvic inlet are frequently referred to as landmarks, both in obstetric 
writings and in practice. They are : 1. The sacro-vertebral angle, or the 
promontory of the sacrum. The angle is formed by the inclination of 
the pelvis, the intervertebral cartilage between the last lumbar and the 
first sacral vertebroe being wedge-shaped, with its base to the front. 
(Fig. 148.) 2. The sacro-iliac joints, or rather the points at which they 
are met by the ilio-pectineal lines. 3. The ilio-pectineal eminences 
situated on the pubic bones close to the ilio-pubic junctions. 4. The 
symphysis pubis. 

The Outlet or Inferior Strait of the Pelvis. The anatomical outlet of 
the pelvis is bounded by the summit of the subpubic arch, the ischial 
tuberosities, and the tip of the coccyx. The outline is that of a lozenge- 



THE MECHANICAL ELEMENTS OF LABOR. 



163 



shaped figure whose angles have been rounded. (Fig. 146.) Owing to 
the distensibility of the sciatic ligaments, to the yielding character of the 
coccyx, and, to some extent, of the sacro-iliac joints, the contour of the 
outlet becomes ovate at the expulsion of the head. (Fig. 147.) 



Fig. 146. 




Outlet of pelvis. 



It will presently be seen that the superior and the inferior strait in 
the obstetric sense are not identical with the anatomical brim and outlet 
respectively. 

Obstetric Landmarks at the Outlet. Anatomical points about the outlet 
which are of special importance as obstetric landmarks are the following: 

1. The tip of the coccyx, and of the sacrum. 

2. The subpubic arch. 3. The ischial tuber- 
osities. 4. The ischial spines. 5. The ob- 
turator foramina. - 

Sacro-sciatic Ligaments. The greater and 
the lesser sacro-sciatic ligaments contribute 
to the formation of the more resistant por- 
tion of the parturient canal, which is mainly 
formed by the bones. 

The greater sacro-sciatic ligament arises 
from the posterior inferior spine of the ilium 
and from the side of the sacrum and coccyx, 
narrows and thickens in the middle of its 
length, broadens again at its anterior attach- 
ment, and is inserted into the inner surface 
of the ischial tuberosity, sending forward a 
falciform process upon the ischial ramus. 
(Fig. 148.) 

The lesser sacro-sciatic ligament takes its origin from the side of the 
sacrum and of the coccyx, and passing in front of the greater is inserted 
into the spine of the ischium. (Fig. 148.) 

The open spaces between the greater and the lesser sciatic notches and 
the ligaments are respectively the greater and the lesser sciatic foramina. 

The Cavity of the True Pelvis is bounded posteriorly in the main by the 
sacrum and the coccyx, anteriorly by the pubic bones and their rami, 
laterally by the lower portions of the ilia and the bodies, tuberosities, 




The outlet as seen from below. 
C. Under surface of the coccyx. 
A P. The antero-posterior, or pubo- 
coccygeal diameter. TE. Transverse 
diameter. R and L 0. Right and 
left oblique diameters. 



164 



PHYSIOLOGY OF LABOR. 



spines, and rami of the ischial bones. It is irregularly cylindrical in 
shape. The posterior wall is smooth, and is concave from above down- 
ward; its depth, measured on the curve of the sacrum and coccyx, is 
11.5 to 12.5 cm., 4J to 5 inches. 

The anterior wall is smooth and concave from side to side; at the 
symphysis its depth is 4 cm., or a little more, If inch. The lateral 
walls corresponding to the broad smooth surfaces of the ischial bones 
are 9 cm. in depth, 3J inches. It will be noted that in the passage of 
the head through the pelvis its posterior pole traverses a much greater 
distance than does the anterior before it escapes from the bony canal. 
As will be seen later, the difference in the extent of the posterior and the 
anterior walls in the soft parts which make up the lower portion of the 
birth-canal is even greater than in the osseous portion of the parturient 
tract. 

Fig. 148. 




Interior surface of left half of pelvis. (Modified from Farabeuf and Varnier.) 
1. Promontory of sacrum. 2. Anterior superior iliac spine. 3. Iliac fossa. 4. Anterior inferior 
iliac spine. 5. Lateral surface of pelvic cavity. 6. Symphysis pubis. 7. Tip of sacrum. 8. First 
piece of coccyx. 9. Spine of ischium. 10. Ischium. 11. Lesser sacro-sciatic ligament. 12. Greater 
sacro-sciatic ligament. 13. Lesser sacro-sciatic foramen SF. Greater sacro-sciatic foramen. OF. 
Obturator foramen. 



Obstetric Planes of the Pelvis. The short curved canal, bounded by 
the bony walls just described, varies somewhat in shape and in size at 
different parts of its course. These variations are best understood with 
the aid of a series of planes drawn transversely through the pelvic cavity 
at different levels. Three are of special obstetric importance. These 
are the plane of the brim, the plane of the outlet, and the middle plane. 



THE MECHANICAL ELEMENTS OF LABOR. 



165 



By the dimensions of these planes the presence or absence of deformity 
in the canal may usually be determined. 

Plane of the Pelvic Brim. The obstetric inlet is the space 
available for the passage of the head at the superior strait. It is not 
strictly coincident with the anatomical brim. The latter is the entrance 
of the lesser pelvis, the former the level of least expansion at the upper 
portion of the pelvic canal. The plane of the obstetric inlet is located 
by the summit of the sacral promontory, the ilio-pectineal line, and the 
posterior surface of the symphysis at a point about 1 cm., J of an inch, 
below its upper margin. (Fig. 149.) 



Fig. 149. 




The diameters of the pelvis. Shows also location of anatomical and obstetric mletand outlet. 

(Faeabeuf.) 

Plane of the Pelvic Outlet. The structures which bound the 
anatomical outlet of the pelvis posteriorly are not wholly fixed, but they 
yield somewhat during labor under pressure of the advancing head. 
The plane of greatest bony resistance at the inferior strait, therefore, is 
not that of the anatomical outlet, but a plane somewhat above it. The 
latter is the inferior strait from the obstetric stand-point. For the ob- 
stetrician the plane of the pelvic outlet is one defined by the tip of 
the sacrum, the ischial tuberosities, and the posterior surface of the 
pubic symphysis at a point immediately above its lower margin. At the 
expulsion of the head from the bony outlet, owing to the yielding char- 
acter of the sciatic ligaments, the shape of this plane becomes ovate, 
with its greatest expansion directed posteriorly. 

The Middle Plane. This plane cuts the upper end of the third 
piece of the sacrum, the middle of the symphysis pubis, and points 



166 



PHYSIOLOGY OF LABOR. 



opposite the centres of the acetabular cavities. The latter plane is 
somewhat larger, the plane of the inferior strait a little smaller than 
that of the pelvic brim. 

Inclination of the Pelvis. The plane of the pelvic brim forms an angle 
with the horizon of from 50 to 60 degrees, according to the posture of 
the body. The upper margin of the symphysis pubis in the erect posi- 




Diagram showing axis and planes of pelvis. 
A B CD. Axis of entire parturient canal. X Anus as distended at acme of expulsion 
of brim. KL. Mid-plane of cavity. M N. Plane of outlet. O P. Axis of brim. QR. 
plane. S T. Axis of outlet. HH. Horizon. EN. Diagonal conjugate diameter. 



. EF. Plane 
Axis of mid- 



tion of the woman is nearly 9 cm., 3| inches, below the level of the 
promontory. The coccyx is 2 cm. above the level of the subpubic arch, 
the pubo-coccygeal line making an angle of 10 degrees with the horizon. 
The direction of the pelvic canal at the inlet turns sharply backward 
from the body axis. Yet it must be remembered that the inclination of 
the pelvis is subject to considerable variation in different postures of the 
body. 



THE MECHANICAL ELEMENTS OF LABOR. 



167 



The Pelvic Diameters and Measurements. 

The varying size and shape of the bony canal at different levels are 
indicated by the varying dimensions of the horizontal planes of the pelvis. 
These dimensions are measured on each plane in four directions : the 
antero-posterior, the transverse, and the two oblique. The several diam- 
eters of these planes taken together are spoken of as the internal diame- 
ters of the pelvis. 

Fig. 151. 




Obstetric diameters of the pelvic brim. 

A A'. Conjugate diameter. TT'. Transverse diameter. LO. Left oblique diameter. 

R O. Right oblique diameter. 



Internal Diameters of the Static or Dried Pelvis. 

At the Brim. The Antero-posterior Diameter at the brim is the 
least distance between the sacral promontory and the pubic symphysis. It 
represents the available interval between the two surfaces for the passage 
of the head. It extends from the middle of the sacral promontory to 
the posterior surface of the symphysis at a point about two-fifths of an 
inch below its upper margin. It is termed the conjugate, or the true 
conjugate, and its value is 11 cm., 4| inches. (Fig. 151.) 

The Transverse Diameter is the greatest distance between the 
ilio-pectineal lines, and measures 13.5 cm., 5 \ inches. The greatest 
transverse diameter of the pelvic brim, however, lies too near the pro- 
montory to be available for the passage of auy of the conventional 
diameters of the foetal head. In a typical relation of head to pelvis, 
therefore, the head never passes in transverse position. (Fig. 151.) 

The Oblique Diameters extend, one from the right, the other from 
the left sacro-iliac joint at its intersection with the ilio-pectineal Hue, to 
the opposite ilio-pectineal eminence. The right oblique springs from 
the right, the left oblique from the left sacro-iliac articulation. Their 
values are each about 12.5 cm., 5 inches. (Fig. 152.) The right 
oblique diameter is slightly longer than the left. It should be noted 



168 



PHYSIOLOGY OF LABOR. 



that by French writers this nomenclature of the oblique diameters is 
reversed, ihe left oblique being that which ends at the left and the right 
oblique that which ends at the right anterior aspect of the pelvic brim. 

At the Middle Plane. The Antero-posterior Diameter is the 
distance from the upper margin of the third piece of the sacrum to the 
posterior surface of the symphysis pubis at the middle point of its depth, 
and is 12.5 cm., 5 inches. 

The Transverse Diameter is the greatest transverse width of the 
pelvis at this plane, and measures 12 cm., 4f inches. 

The Oblique Diameters are not measured from fixed points, and 
are, therefore, valueless for obstetric purposes. 

Fig. 152. 




Obstetric diameters of the pelvic outlet. 
S. P. Sacro-pubic diameter. Bi. I. Bisischial diameter. Bi. S. Bisciatic diameter. 



At the Outlet. The Antero- posterior Diameter of the obstetric 
outlet is a line drawn from the tip of the sacrum to a point just above 
the summit of the subpubic arch. Its value is 11.5 cm., 4 J inches. 

The Greatest Transverse Diameter is the bisischial line, and 
is 11 cm., 4f inches. It is measured from the inner surface of the 
ischial tuberosities at the middle of their posterior borders, and corre- 
sponds in the living pelvis to a line running transversely through the 
anterior margin of the anal orifice. The antero-posterior diameter of 
the anatomical outlet extends from the tip of the coccyx to the summit 
of the subpubic arch, and measures 9 cm.. 3| inches. The distance be- 
tween the ischial spines, the bisischiatic diameter, is 10.5 cm., 4 \ inches. 

The oblique diameters at the outlet are of little practical importance, 
since their posterior extremities do not rest on fixed points. (Fig. 152.) 

Shape of the Pelvic Canal. It will be seen by comparing the 
dimensions of the different planes that the pelvic canal grows progres- 
sively narrower in its transverse diameter from the brim to the outlet, 
the difference at these two levels amounting to 2.5 cm. In the sagittal 
direction the canal is narrowest at the brim and most roomy at the 
middle plane. The antero-posterior diameter at the middle plane is 



THE MECHANICAL ELEMENTS OF LABOR. 



169 



1.5 cm. longer, at the inferior strait it is 5 cm. longer than at the 
inlet. 

Measurements of the Dynamic Pelvis. 

Internal Measurements. The dimensions thus far stated relate to the 
anatomical or dried pelvis. In the pelvis of the living woman — the 
dynamic pelvis — the measurements are more or less modified by the 
presence of the soft structures which line the bony canal. The internal 
diameters are all diminished from an eighth to a quarter of an inch by 
the thickness of the soft parts. 

At the brim, owing to the encroachment of the ilio-psoas muscles upon 
the pelvic space, the transverse diameter is reduced still more, so that, 
while in the anatomical pelvis the transverse is the longest dimension a,t 
the inlet, the oblique is greatest in the obstetric patient. (Fig. 153.) 

Fig. 153. 




Diameters of the pelvic inlet as affected by the principal soft parts. The oblique is the longest 
practicable diameter in the dynamic pelvis. (Farabeuf.) 

External Measurements. The external bear a fairly constant relation 
to the internal dimensions of the pelvis. External measurements are, 
therefore, useful to the obstetrician in determining the probable capacity 
of the pelvic canal. They are especially valuable for the reason that 
they may be more readily and more accurately determined in the living 
subject than can the internal diameters. The more important external 



170 PHYSIOLOGY OF LABOR. 

measurements are : The External Conjugate Diameter, or Diameter of 
Baudelocque, the Interspinal, and the Intercristal Diameters. 

The External Conjugate Diameter is the distance from the 
fossa immediately below the spine of the last lumbar vertebra to the 
most prominent point on the anterior surface of the pubes, two-fifths of 
an inch below the upper margin of the symphysis, and its value is 
20.3 cm., 8 inches. 

The external conjugate is obviously subject to considerable variation, 
dependent on the thickness of the bony structures and of the overlying 
soft parts. The difference between the external and the internal conjugate 
ranges from 7 to 12.7 cm., 2|- to 5 inches, the average being 9 cm., 3 \ inches. 

The Interspinal Diameter is the distance between the outer 
aspects of the anterior spines of the ilium, measured from the outer 
margins of the insertion of the sartorii, 25.5 cm., 10 inches. 

The Intercristal Diameter is the greatest distance between the 
outer borders of the iliac crests, 28 cm., 11 inches. 

External Oblique Diameters. In addition to the foregoing 
may be mentioned the external oblique diameters ; they are respectively 
the distance from the posterior superior spine of one to the anterior 
superior spine of the opposite iliac bone, 22 cm., 8f inches. 

The Bisischial Diameter, 11 cm., 4| inches, since it may be 
measured externally as well as internally, may be enumerated with the 
external diameters. 

The Bitrochanteric Diameter, which is the distance from one 
trochanter major to its companion, is usually included with the pelvic 
measurements. Its value is 31 cm., 12J inches. 

The following tabular statement of the pelvic measurements will be 
found convenient for reference : 

Summary of Internal Measurements of the Dried Pelvis. 

Antero-poslerior diameters. Oblique diameters. Transverse diameters. 

Brim . .11cm, 4% inches. 12.5 cm., 5 inches. 13.5 cm., 5% inches. 

Mid-plane . 12.5 cm., 5 inches. 12 cm., finches. 12 cm., 4% inches. 

Outlet . . 11 5 cm., 4% inches. 11cm., 4% inches. 

Circumference of the brim, 40 cm., 16 inches ; of the outlet, 33 cm., 13 inches. 

The internal diameters of the dried pelvis, as stated in the following 
table, are sufficiently exact for practical purposes, and they have the 
advantage of being easily remembered : 

Approximate Internal Measurements of the Pelvis. 

Antero-posterior. Oblique. Transverse. 

Brim 4 inches. 4% inches. 5 inches. 

Mid-plane ...... 4% " 4% 4% " 

Outlet 5 4% 4 " 

Summary of External Measurements of the Dynamic Pelvis. 

External conjugate diameter 20.3 cm., 8 inches. 

Interspinal 25.5 " 10 

Intercristal 28 " 11 

Bitrochanteric . 31 " 12.4 

External oblique 22 " 8% " 

Bisischial 11 " 4% " 

The average external circumference of the pelvis measured over the 
symphysis, just below the iliac crests, and across the middle of the sacrum 
is one yard. 



THE MECHANICAL ELEMENTS OF LABOR. 



171 



Differences Between the Male and the Female Pelves. 

Until the age of puberty the pelves of the opposite sexes present no 
striking differences of structure. The distinctive peculiarities of the 



FrG 154. 




Female pelvis. 
Fig. 155. 




Male pelvis. 



female pelvis are, in the main, developed after that period. In the 
mature woman the distinguishing marks of the pelvis as compared with 
that of the male are chiefly these : 

As a whole, the bones are lighter and more slender. The false pelvis is 



172 PHYSIOLOGY OF LABOR. 

somewhat smaller and the true pelvis larger in all diameters and of 
shallower depth. 

The brim is less triangular and its capacity greater, the sacro- vertebral 
angle is more prominent. The ilio-pectineal lines are more strongly 
curved, and the pubic spines are farther apart. 

The cavity is less funnel-shaped, and all its horizontal diameters are 
greater. The sacrum is shorter and broader, and it presents a more 
nearly uniform antero-posterior curvature. 

The outlet is larger; the width of the subpubic arch is greater, 80 to 
100 degrees or more, the angle in the male measuring from 70 to 80 
degrees. The depth of the symphysis pubis is less. 

Differences Dependent on Racial Characteristics. 

Marked differences in the form and size of the pelvis obtain in differ- 
ent races. Yet these variations of type are largely due, as Spiegelberg 
has intimated, to conditions of nutrition and activity. 

Pelvic deformities are most frequent in the inferior races. A larger 
proportion of dwarfed pelves is observed in races of a low order of 
physical development. A common deviation from the normal Caucasian 
type consists in a relative elongation of the antero-posterior dimensions 
of the pelvis as compared with the transverse. Thus the pelvis of the 
Australian is nearly circular in horizontal outline, and in Bush women 
the antero-posterior exceed the transverse diameters. The pelvis of the 
Laplander is small. 

Obstetric Anatomy of the Soft Parts of the Parturient Tract. 

The Uterus forms a part of the parturient canal. Yet, as will be seen 
in connection with the physiology of labor, the organ resolves itself into 
two segments which sustain very different relations to the parturient 
process, an upper, contractile, and a lower, passive, segment. The upper 
segment is of interest chiefly as the principal source of the propelling 
power, the lower, the seat of resistance at the beginning of labor, belongs 
more properly to the passages than does the contractile portion of the 
organ. 

The Soft Parts of the Pelvis which concern the obstetrician are chiefly 
the muscles which line the bony excavation and the structures which 
compose the pelvic floor. The former, as already stated, reduce slightly 
the capacity of the bony cavity; the latter supplement the osseous por- 
tion of the parturient tract. Lying immediately above the lateral mar- 
gins of the brim, the iliacus and psoas muscles diminish the transverse 
width of the bony inlet to the extent of about a quarter of an inch on 
each side. The external iliac vessels run along the inner borders of these 
muscles. The main trunk of the lumbar plexus follows the course of 
the psoas, and the crural nerve runs between the psoas and the iliacus 
muscles. 

The median portion of both the anterior and the posterior pelvic walls 
is devoid of muscular coverings. On either side of the median section 
lie the piriformis posteriorly and the obturator internus anteriorly and 
laterally. These muscles are thin and are so located as scarcely to lessen 
appreciably the capacity of the pelvis. 



THE MECHANICAL ELEMENTS OF LABOR. 173 

The Pyriformis is a fan-shaped muscle arising by digitations from 
the anterior aspects of the second, third, and fourth sacral vertebrae, 
from the upper margin of the greater sciatic notch, and from the ante- 
rior surface of the greater sacro-sciatic ligament; it passes out of the 
pelvis by the greater sacro-sciatic foramen to its insertion in the femur. 
The nerves of the sacral plexns lie in front of this muscle. 

The Obturator Internus Muscle arises from the inner surface of 
the obturator membrane, from the fibrous arch which completes the canal 
for the obturator vessels and nerves, and from the inner surface of the 
innominate bone anteriorly between the obturator foramen and the 
margin of the ischio-pubic ramus, and laterally over an area extending 
backward to the sciatic notch, upward to the brim, and downward to 
the outlet; a few fibres arise from the obturator fascia which covers the 
internal surface of the muscle; its fibres converge and pass out through 
the lesser sacro-sciatic foramen to be inserted into the great trochanter. 

The Bladder in the front portion of the pelvic cavity does not when 
empty appreciably diminish its capacity. Moreover, during the begin- 
ning stage of labor, as will be explained later, the greater portion of this 
viscus is drawn up above the inlet of the pelvis. 

The Rectum at the brim lies in front of the left sacro-iliac joint ; it 
thence runs inward to descend in the median line along the anterior sur- 
face of the sacrum and the coccyx. It encroaches but little on the pelvic 
space except when distended, yet the left oblique diameter at the brim, 
which in the dried pelvis is shorter than the right, is rendered still more 
so by the presence of the rectum, especially when the latter is filled. 
The greater frequency with which the head enters the pelvis in the 
right oblique diameter than in the left is explained by these facts. 

The Pelvic Floor comprises the soft structures which close the 
outlet of the bony pelvis and give support to the pelvic and abdominal 
contents. Its upper limit is the peritoneum except where that structure 
is lifted off to be reflected over the pelvic viscera. Its lower surface 
is the skin. At its median portion it is obliquely traversed by three 
muscular slits, the urethra, the vagina, and the rectum, all approxi- 
mately parallel with the pelvic brim, save that the lower end of the 
rectum turns backward nearly at a right angle with the vagina. 

The posterior vaginal wall and the soft structures behind it constitute 
the sacral segment ; the anterior wall of the vagina and the soft parts in 
front of it compose the pubic segment of the pelvic floor (Hart). 

In labor the pubic segment of the floor is drawn upward and the 
sacral segment is distended and thrust downward as the foetus descends 
through the infra-osseous portion of the parturient canal. The resiliency 
of the posterior segment of ihe floor holds the foetal mass in close relation 
with the ischio pubic rami during the completion of the birth, and assists 
in its final expulsion. 

Measurements. In the nullipara the distance from the coccyx to the 
anus is 4.5 cm., If inch; from the anus to the lower margin of the 
vulvar orifice, 3.2 cm., 1J inch; in the parous woman the latter distance 
is 2.5 cm., 1 inch; in the primigravida at term, 3.8 cm., 1 J inch. The 
greatest transverse width of the pelvic floor, on the bisischial line, is 
11 cm., 4f inches; the perpendicular thickness at the anus is about o 
cm., 2 inches. In the non-gravid woman the average projection below 



174 



PHYSIOLOGY OF LABOR. 



a line drawn from the tip of the coccyx to the summit of the subpubic 
arch is about 2.5 cm., 1 inch. The length of the sacral segment during 
labor at the acme of expulsion — coccyx to lower edge of vulvar orifice — 
is 15 cm. , 6 inches. 

The more important component parts of the pelvic floor are its mus- 
cular structures and fascial sheets. On the latter its strength and 
supporting power mainly depend. 

For a detailed description of the anatomy of the pelvic floor the reader 
is referred to the chapter on The Female Pelvic Organs. 



Fig. 156. 



Fig. 157. 




Axis of the bony pelvis. 
c d. Axis of iulet. cf. Axis of bony pelvis. 



Axis of the birth-canal. 
r. Anus, a b. Plane of outlet of com- 
pleted canal, e. Perpendicular to plane 
or axis of expulsion. 



The Parturient Axis. It is obvious that an infinite number of pelvic 
planes may be drawn in addition to the cardinal planes previously 
described. All, if extended, would meet in front of the pubic joint. 
The mathematical axis of the pelvic canal is a line which pierces each 
of these planes perpendicularly at its centre point. Such a line is a 
curved line with its concavity forward, and it represents very nearly 
the course which the foetal head follows in its descent through the 
pelvis in typical labors. The axis of the inlet prolonged strikes the 
tip of the coccyx and a point on the abdominal wall near the umbilicus. 
The axis of the obstetric outlet of the bony pelvis if extended would 



THE MECHANICAL ELEMENTS OF LABOR. 175 

pass immediately in front of the sacral promontory. The course of the 
osseous portion of the canal depends upon the longitudinal curvature 
of the sacrum, and varies accordingly. The plane of the vulvo- vaginal 
ring at the moment when the foetal head is expelled is nearly parallel 
with the long axis of the mother's body. The outlet of the soft parts, 
therefore, at the acme of expulsion, looks almost directly forward. 
(Fig. 157.) 

III. The Foetus. 

The head, the upper part of the trunk, and the breech of the foetus 
each fills the pelvis more or less completely during its passage through 
it, and each has sufficient rigidity to retain its primal shape in some 
degree during labor. These parts of the foetal mass, therefore, all sus- 
tain an important relation to the mechanism of labor. The head, how- 
ever, is much larger in proportion to the trunk in the foetus than in the 
adult. As a whole, its diameters are greater than those of the shoulders 
or the breech and thighs, and are more incompressible. It follows that 
the principal resistance to the passage of the child through the pelvis 
is offered by the head. While the body of the foetus cannot be wholly 
neglected in the study of the mechanism of labor, it is with the head 
that obstetric questions are mainly concerned. 

Obstetric Anatomy of the Foetal Head. For the obstetrician the foetal 
head present two general divisions: 1, the cranial vault; 2, the cranial 
base and face. The former, owing to the semi-cartilaginous character 
and the mobility of its bones, is plastic, a fact of great importance in 
facilitating the passage of the head through the pelvis; the latter is 
firm and unyielding, its bony structures being more highly ossified and 
more firmly united. Protection is thus afforded during birth to the 
ganglia at the base of the brain. 

It is necessary to bear in mind, however, that the plasticity of the foetal 
head differs in different infants at term. The degree of ossification and 
the firmness of union between the cranial bones in the fully developed 
foetus are subject to considerable variation, and the hardness of the head 
is an essential element in the labor. 

The Boxes of the cranial vault are the two parietal, the two frontal, 
the squamous portion of the occipital and those of the two temporal 
bones. They are united only by the unossified external periosteum and 
by the dura mater. Both the flexible character of the bones and the 
existence of membranous interspaces contribute to the plasticity of the 
cranial vault. 

The Sutures of the vault are the membranous intervals between two 
adjacent bones. Those of obstetric importance are the sagittal or inter- 
parietal, the frontal or interfrontal, the coronal or fronto-parietal, the 
lambdoidal or occipito-ip&rietal sutures. (Figs. 158 and 159.) 

The Fontanelles are the greater spaces formed by the widening 
out of the sutures between the angles of three or four adjacent bones. 

The anterior fontanelle, or bregma, is situated at the junction of the 
sagittal, the coronal, and the frontal sutures. It is identified in the 
vaginal examination during labor by the following characters. It is 
kite-shaped, or quadrangular, with its most acute angle forward. Its 
average diameter is one inch. Its size, however, varies in different 



176 PHYSIOLOGY OF LABOR. 

foetal heads, and is much diminished by overlapping of the bones when 

the head is firmly wedged in the pelvis. Four lines of sutures run into it. 

The posterior fontanelle is formed at the junction of the sagittal and 

the lambdoidal sutures. It presents to the examining finger the follow - 

FlG. 159. 





Anterior and posterior fontanelles, sagittal, lambdoidal, coronal, and frontal sutures. 

ing distinguishing marks : It is small, usually a mere depression, barely 
perceptible to the finger-tip. Three lines of suture run into it. Behind 
it is the squamous or triangular portion of the occipital bone, which is 
movable upon the basilar portion by a hinge-like joint of fibrous tissue. 

Fig. 160. 




Foetal head seen from above, showing false fontanelle between the anterior and the posterior 
fontanelle. (After Ribemont-Dessaignes and Lepage.) 

In exceptional instances in well-ossified heads this fontanelle is absent. 
Frequently during labor the interspace is obliterated by the crowding 
together or overlapping of the cranial bones. 

Temporal Fontanelles. A fontanelle exists on either side of the head 



THE MECHANICAL ELEMENTS OF LABOR. 



177 



at the junction of the temporal with the parietal and occipital bones. 
They are of little obstetric interest, except for the fact that in rare cases 
one of them may fall within reach of the examining finger and be mis- 
taken for the occipital fontanelle. 

False Fontanelles, due to failure of ossification, are exceptionally 
observed either in the body of the bone or in the course of a suture. 
(Fig. 160.) 

Wormian Bones, Rarely there are small, supernumerary bones in the 
interparietal space. They are the result of irregular ossification, and are 
known as Wormian bones. 

In the examination of the head for diagnosis of position, the practi- 
tioner must have in mind the possibility of being misled by these anomalies. 

Protuberances. The cranial bones present five protuberances which 
are of interest as obstetric landmarks. They are the occipital, the two 
parietal, and the two frontal. The occipital protuberance is situated 2.5 
cm., 1 inch, or more behind the posterior fontanelle. The parietal pro- 
tuberance or boss is the bony eminence at the centre of each parietal bone. 
The frontal protuberance is the eminence at the centre of each frontal bone. 

The Vertex is that portion of the head between the anterior and the 
posterior fontanelles and extending laterally to the parietal eminences. 

The Occiput is the part of the head behind the posterior fontanelle. 

The Sinciput is that portion of the cranial vault in front of the 
bregma. 

Fig. 161. 




The diameters of the foetal head. (Modified from Farabeuf and Varnier.) 
O F. Occipitofrontal. O B. Suboccipito-bregmatic. T B. Trachelo-bregmatic. The maximum 
diameter, occipito-mental, is indicated by the long dotted arrow. Measurements are in centimetres. 

Measurements of the Foetal Head. Obviously the obstetrician must take 
into account the shape and dimensions of the foetal head, as well as of 
the pelvis. Not only the size, but the configuration of the cephalic mass 
is an essential element in the relation of the head to the birth-canal. 
These elements in the obstetric problem are best understood with the aid 
of a series of head diameters and circumferences measured in different 

12 



178 



PHYSIOLOGY OF LABOR. 



planes. The diameters of the head commonly made use of are the 
occipitofrontal, the occipito-mental, the suboccipito-bregmatic, the 
biparietal, the bitemporal, the bimastoid, the fronto-mental, and the 
trachelo-bregmatic. (Figs. 161 and 162.) 

The occipito-frontal diameter is measured from the tip of the occipital 
protuberance to the root of the nose. 

The occipito-mental diameter extends from the occipital protuberance 
to the centre of the lower margin of the chin. 

The suboccipito-bregmatic diameter extends from the junction of the 
nucha and the occiput to the centre of the bregma. 

The suboccipito-frontal extends from the junction of nucha and occiput 
to the summit of the forehead. 

The biparietal diameter is measured through the centres of the parietal 



eminences. 



Fig. 


162. 






L 










/ i 










™^l 


n 






\ V^ 11 


o^^^ 





Engaging diameters of the flexed head. (After Farabeuf and Varnier.) 
P P. Biparietal diameter, 9 cm. B. Suboccipito-bregmatic diameter, 9.5 cm. 

The bitemporal is the distance between the lower extremities of the 
coronal suture. 

The bimastoid is the distance between the mastoid apophyses. 

The fronto-mental diameter extends from the summit of the forehead 
to the centre of the lower margin of the chin. 

The cervico-bregmatic extends from the junction of neck and chin to 
the centre of the bregma. 

The average values of these diameters are given in the following table: 

Average Diameters of the Fcetal Head. 



Occipito-frontal diameter 












11.5 cm. 4% inches 


Occipito-mental " 












14 « 


oV 2 " 


Suboccipito bregmatic diameter 












9.5 ' 


3% " 


Suboccipito-frontal " 












11 ' 


±y 8 « 


Biparietal diameter 












9.5 ' 


z% " 


Bitemporal " . . 












8 ' 


sy 8 " 


Bimastoid " . 












7 ' 


2% » 


Fronto-mental diameter . 












9 


3>< " 


Trachelo-bregmatic diameter . 












9.5 ' 


3% « 



THE MECHANICAL ELEMENTS OF LABOR. 179 

Approximate Diameters of the Fcetal Head. The approxi- 
mate diameters of the foetal head may for easy memorizing be stated with 
sufficient accuracy for practical purposes as follows : 

Biparietal 9 cm. 3% inches. 

Suboccipito-bregmatic 9 !< 3% " 

Fronto-rnental 9 " 3% " 

Occipitofrontal ,...*.-.... 11.5 " 4% " 

Occipito-mental 14 " 5% " 

Planes of the Foetal Head. Just as the pelvis is studied with the aid of 
the horizontal planes, so the size and shape of the head in its relation 
to the birth-canal may more easily be appreciated with the help of cross- 
sections made through its more important diameters. Most useful for 
this purpose are the occipito-mental section through the biparietal and 
the occipito-mental diameters, the occipitofrontal section through the 
biparietal and the occipitofrontal diameters, the suboccipito-frontal 
through the bitemporal and the suboccipito-frontal diameters, the sub- 
occipito-bregmatic through the biparietal and the suboccipito-bregmatic 
diameters. By comparison of these sectional planes it will be seen that 
the suboccipito-bregmatic plane, which is the plane that falls in relation 
with the different pelvic planes successively as the head descends, is not 
only the smallest but is nearly circular. It measures, after the head is 
well moulded to the pelvis, 9 cm., about 3 J inches, in the biparietal, 
and but little more in the opposite diameter. Its circumference is about 
33 cm., 13 inches, while the occipitofrontal circumference is 34.5 cm., 
13 J inches, and the occipito-mental 35.5 cm., 14 inches. The sub- 
occipito-bregmatic is the plane which engages in complete flexion of the 
head. Thus it is obvious that the difference between a fully flexed and 
a partially extended head may make all the difference between an easy 
and an impossible delivery. 

Circumference of the Foetal Head. The cross-sections of the head whose 
circumferences are in most cases the maximum circumferences engaging 
in the pelvis are the suboccipito-bregmatic and the suboccipito-frontal. 
The occipito-frontal it is well to note, yet the latter is of little practical 
importance. These cross-sections extend through the corresponding 
diameters respectively. Their circumferences are as follows : 

Suboccipito-bregmatic circumference 33 cm. 13 inches. 

Suboccipito-frontal " 35 " 13% " 

Occipito-frontal " 34.5 " 13% 

Moulding. Comparing the dimensions of the foetal head with one 
another it will be seen that the head during its descent through the 
pelvis is an irregular cylindrical mass, the long axis of which is 14 cm., 
5 \ inches, and the transverse 9.5 cm., 3f inches. 

Normally the long axis of the cylinder lies nearly in relation with the 
axis of the birth-canal; the engaging diameters of the average head, 
those which lie across the parturient tract, differ little from those of the 
maternal pelvis. The value of the suboccipito-bregmatic circumference 
is the same as that of the pelvic outlet. 

In most births the cylindrical form of the cephalic mass becomes still 
more pronounced during labor, owing to the moulding which takes place 
from the pressure effects of the birth-canal. The elongation of the 



180 PHYSIOLOGY OF LAB OB. 

cylinder is farther increased by the formation upon the presenting part 
of the caput succedaneum, to be described in another chapter. 

The principal diameters of the head are all affected in greater or less 
degree by the moulding of the head in its passage through . the birth- 
canal. The biparietal is reduced in ordinary labor by about 0.6 cm., 
J inch. The suboccipito-bregmatic and the suboccipito-frontal are cor- 
respondingly shortened. The occipito-mental is lengthened. In a word, 
the engaging diameters are compressed, and there is a corresponding 
elongation of the diameter which is in relation with the axis of the 
parturient tract. The moulding is chiefly the result of overlapping of 
the cranial bones. It may be noted in passing that the measurements 
of the head for record should be taken after it has resumed its normal 
shape. 

The head undergoes in slight degree a total reduction in volume dur- 
ing its passage through the pelvis, owing to the fact that a portion of 
the cerebro-spinal fluid and of the contents of the intracranial blood- 
vessels is forced out of the cranial cavity by compression. 

The plasticity of the head is obviously an essential factor in the par- 
turient process. The hardness of the cranial vault is, therefore, always 
to be taken into account in estimating the proguosis of labor. 

The Trunk. The trunk diameters are small, and moreover are so com- 
pressible as to render them of relatively little importance in the mech- 
anism of labor. The longest of the trunk diameters is the bisacromial. 
Its length is 12 cm., 4 J inches; but it is reducible to the extent of at 
least 2 or 3 cm. The antero-posterior or sterno-dorsal diameter at the 
level of the shoulders is 8.5 cm., 3f inches, and is reducible to 8 cm. 
The average chest measure (circumference) is 12^ inches. The bitro- 
chanteric diameter is 9 cm., 3 J inches. The antero-posterior diameter 
at the breech, the sacro-pubic, is 5.5 cm., 2 J inches. With the super- 
added thickness of the thighs flexed upon the abdomen, the antero- 
posterior diameter is nearly doubled. 

Length and Weight of the Mature Fcetus. The length of the child at 
term is usually between 46 and 51 cm., 18 and 20 inches. The average 
weight is 3150 to 3290 grammes, 7 to 7\ pounds, males weighing more 
than females, and first, as a rule, less than subsequent births. The usual 
birth-weight may be said to vary from 2700 to 5400 grammes, 6 to 11 
or 12 pounds. In very rare instances the latter limit is exceeded, and 
phenomenal weights of more than 9000 grammes, 20 pounds, have been 
recorded. There is usually a progressive gain in the weight of the 
children in successive pregnancies of the same mother till the fourth 
or fifth. 

Mobility of the Foetal Head Upon the Spinal Column. The movements of 
extension or flexion and of rotation of the head upon the trunk sustain 
important relations to the mechanism of labor, as will be seen in connec- 
tion with the discussion of that subject. These movements are favored 
by the laxity of the joints in the cervical portion of the spinal column. 
The limit of safe rotation of the head upon the trunk is generally believed 
to be 90 degrees on either side. Tarnier, however, points out that the 
rotation may be continued without injury to the spinal cord or to the liga- 
ments till the face looks directly backward. The torsion is not confined 



THE MECHANICAL ELEMENTS OF LABOR. 181 

to a single point in the spinal column, but is distributed along the upper 
portion of its length. 

PRESENTATION, POSITION, AND POSTURE OF THE FCETUS. 

Presentation is, in general terms, the relation of the long axis of the 
foetal ovoid to the uterine axis. Under this definition we have two vari- 
eties of presentation : longitudinal and transverse. 

Longitudinal Presentation is that in which the long axis of the 
foetal ovoid corresponds with the axis of the uterus, either the cephalic 
or the pelvic extremity offering at the brim of the pelvis. 

Transverse Presentation is that in which the long axis of the 
foetal mass lies across the long axis of the uterus. Except very rarely, 
however, its direction is not transverse but oblique. In this presenta- 
tion any part of the foetus, except the cephalic or the podalic extremity, 
may offer primarily at the pelvic inlet. 

As commonly employed the term presentation refers to the part of the 
foetus which presents at the pelvic brim. Thus we have cephalic and 
breech as subvarieties of longitudinal presentation; vertex, face, and brow 
as subvarieties of cephalic presentation; breech and foot as subvarieties of 
pelvic presentation; shoulder, arm, and hand as subvarieties of transverse 
presentation. Since in transverse presentation the shoulder ultimately 
becomes the presenting part, transverse is also known as shoulder pre- 
sentation. 

The term presenting part is used to denote the part of the foetal ovoid 
which offers to the examining finger. It is, therefore, synonymous with 
presentation in the sense last referred to. 

The varieties and subvarieties of presentation may be summarized as 
follows : 

Presentations. 

1. Longitudinal. 

A. Cephalic, (a) Vertex; (b) face; (c) brow. 

B. Breech, (a) Breech; (6) knee; (c) foot. 

2. Transervse. 

(a) Shoulder; (b) arm; (c) hand. 

Relative Frequency of the Different Presentations. The vertex presents 
in about 97 per cent, of all labors at term. Spiegelberg found cephalic 
presentations in 97 per cent, of the children in 97,871 labors; Lepage 
in 97.32 per cent, of 3032 primiparse, and in 97.24 per cent, of 3598 
multiparse, at the Clinique Baudelocque. The breech presents in about 
1.6 per cent, of all labors; transverse presentation occurs in 0.5 per 
cent. The preponderance of vertex presentations is due mainly to adap- 
tation of the foetal ovoid to the shape of the uterus, and in some degree 
to gravity, the cephalic being the heavier extremity of the foetus. 

Position. Position is the relation of the presenting part to the quad- 
rants of the pelvic brim, the quadrants being those into which the brim 
is divided by the antero-posterior and the transverse diameters. For 
each presentation there are four positions. They are named according 
to the particular quadrant confronted by the presenting part, sometimes 
from some anatomical point at the brim selected for its prominence. 



182 PHYSIOLOGY OF LABOR. 

In vertex, face, and breech presentations the long diameter of the 
presenting part engages in one of the oblique diameters of the pelvic 
inlet. In vertex presentation the occiput looks to the right or to the 
left anterior or to the right or left posterior quadrant. When the occi- 
put confronts the left auterior quadrant, the position is left occipito- 
anterior; if it faces the right anterior quadrant, the position is right 
occipito-anterior, and so on. The positions are sometimes spoken of as 
first, second, third, and fourth, the left occipito-anterior being the first, 
and the others following in order from left to right around the pelvic 
brim. Face positions are named in similar manner according to the 
direction of the chin — left mento-anterior, etc.; breech positions, accord- 
ing to the direction of the sacrum — left sacro-anterior, etc.; shoulder 
positions, according to the direction of the scapula — left scapulo- 
anterior, etc. 

Vertex Positions. 

Left occipito-anterior. L. O. A. 
Right occipito-anterior. R. O. A. 
Eight occipito-posterior. R. O. P. 
Left occipito-posterior. L. O. P. 

The relative frequency of the different vertex positions may be roughly 
stated at 75, 20, 4, and 1 per cent, respectively. 

Face Positions. 

Left mento-anterior. L. M. A. 
Right mento-anterior. R. M. A. 
Right mento-posterior. R. M. P. 
Left mento-posterior. L. M. P. 

Breech Positions. 

Left sacro-anterior. L. S. A. 
Right sacro-anterior. R. S. A. 
Right sacro-posterior. R. S. P. 
Left sacro-posterior. L. S. P. 

Transverse or Shoulder Positions. 

Left scapulo-anterior. L. Sc. A. 
Right scapulo-anterior. R. Sc. A. 
Right scapulo-posterior. R. Sc. P. 
Left scapulo-posterior. L. Sc. P. 



THE MECHANICAL ELEMENTS OF LABOR. 183 

Fig. 163. 




Vertex. Left occipito-anterior position. (Farabeuf and Varnier.) 
Fig. 164. 




Vortpv Ttiorht. nnninitn-antPTinT nnsition. fFARAREUF and VarNIER.1 



184 



PHYSIOLOGY OF LABOR. 

Fig. 165. 




Vertex. Right occipito-posterior position. (Farabeuf and Varnier. 
Fig. 166. 




Vertex. Left occipito-posterior position. (Farabeuf and Varnier.) 



THE MECHANICAL ELEMENTS OF LABOR. 
Fig. 167. 



185 




Face. Left mentoanterior position. (Farabetjf and Varnier.) 

Fig. 168. 




Face. Right niento-anterior position. (Farabeuf and V 



186 



PHYSIOL OGY OF LAB OB. 

Fig. 169. 




Face. Right mentoposterior position. (Farabeuf and Varnier.) 
Fig. 170. 




Face. Left mento-posterior position. (Farabeuf and Varnier. 



THE MECHANICAL ELEMENTS OF LABOR. 
Fig. 171. 



187 




Breech Left sacroanterior position. (Farabeuf and Vaknier.) 



Fig. 172. 




Breech. Right sacro-anterior position. (Farabeuf and Vaknier.) 



188 



PHYSIOLOGY OF LABOR. 
Fig. 173. 




Breech. Right sacro- posterior position. (Farabeuf and Vabnier.) 
Fig. 174. 




Breech. Left sacro-posterior position. (Farabeuf and Varnier.) 



THE MECHANICAL ELEMENTS OF LABOR. 

Fig. 175. 



189 




Shoulder. Left scapuloanterior position. (Farabeuf and Varnier.) 
Fig. 176. 




Shoulder. Right scapulo-anterior position. (Farabeuf and Varnier.) 



190 



PHYSIOLOGY OF LAB OB. 



F:g. 177. 




Shoulder. Right scapuloposterior position. (Farabeuf and Varnier. 



Fig. 17 




Shoulder. Left scapulo-posterior position. (Farabeuf and Varnier.) 



THE MECHANICAL ELEMENTS OF LABOR. 191 

Posture, or the attitude of the foetus, is the relation of the foetal mem- 
bers to one another. The normal posture of the foetus during pregnancy 
and parturition is one of flexion. The head is flexed, the arms are 
folded on the chest, the legs are flexed upon the thighs, and the thighs 
ou the abdomen. The back is arched, and the foetal mass presents an 
ovoid shape. The foetal posture is the result partly of the primitive form 
of the embryo, mainly of the uterine pressure forces. As an element in 
the labor, posture is most important as relates to the head. 



CHAPTER VIII. 

THE MECHANISM AND CLINICAL COURSE OF NORMAL LABOR. 

Definition of Normal Labor. The term eutocia is applied to labors which 
terminate without artificial aid and without injury to mother or child. 
All such labors are in a sense natural or normal, and in most obstetric 
text-books are so classified. In the present work the term normal labor 
will be restricted to labors in which there is no element of dystocia, those, 
in other words, in which all the mechanical elements are normal and 
which are not rendered dangerous to mother or child by complications 
independent of the mechanism. Under this definition only uncom- 
plicated labors in which the vertex presents in anterior position will be 
classed as normal. 

Stages of Labor. 

Labor is divided into three stages: 

The first stage, or stage of dilatation, ends with the fall dilatation of 
the utero-cervical zone. 

The second stage, or stage of expulsion, ends with the birth of the child. 

The third stage, or placental stage, ends with the expulsion of the 
placenta and membranes and the complete retraction of the uterus. 

The Duration of Normal Labor. 

It is difficult to determine clinically the precise time when labor begins. 
For practical purposes, it is sufficient to date the onset of the parturient 
process from the time the woman is conscious of regularly recurring 
uterine contractions. In many instances, however, occasional pains are 
felt for days or weeks before labor is actively established. On the other 
hand, considerable dilatation is very frequently accomplished without 
pain. Sometimes the labor may cease wholly for a time after it has 
continued for several hours. 

The time occupied by the process of dilatation varies greatly in dif- 
ferent cases. Other things being equal, it is shorter in multipara than 
in primiparse, since the soft parts offer less resistance after the first 
childbirth. It is especially prolonged in aged primiparse, owing to 
excessive rigidity of the cervix uteri and of the pelvic floor in that 
class of parturients. 

In typical normal conditions the average period from the beginning 
of active labor to complete canalization of the utero-cervical zone may 
be fairly stated at from ten to fourteen hours for primiparous and from 
six to eight hours for multiparous women. 

The average length of the second stage is approximately two hours in 
the primipara and one hour in the multipara. 

The expulsion of the placenta usually takes place within a period 
varying from a few minutes to two hours after the birth of the child. 
The average period is about twenty minutes. 
(192) 



MECHANISM AND CLINICAL COURSE OF NORMAL LABOR. 193 

Causes of the Onset of Labor. 

A process like labor, involving so extensive coordinate muscular action, 
implies the existence in the nervous system of controlling motor centres 
for the regulation of the uterine contractions. Though it has been suffi- 
ciently established that there is such a centre in the medulla, from which 
impressions travel, probably down the cord and through the sacral 
plexus to the uterus, rhythmical contractions are not solely dependent 
on this centre, as is proved by the fact that contractions go on after 
connection with the medulla has been severed. For example, rhythmical 
contractions have been known to take place in the horn of a uterus which 
had been removed while labor was going on. In addition to the nerve 
centre in the medulla we have the cervical ganglion, an extensive plexus 
of nervous matter lying on the posterior vaginal fornix and intimately 
connected with the uterus by numerous filaments. It is formed by the 
union of nerve cords from the hypogastric plexus, and it receives fila- 
ments from the second, third, and fourth sacral nerves. Whether the 
motor impulses travel by the cord or pass by the path of the sympa- 
thetic trunk is a question that cannot be answered finally at the present 
time. Lusk and others have reported cases of successful labor in 
w r omen having paralysis of the lower extremities, retention of urine, 
and incontinence of feces. Observations of this character would seem to 
show that the cord is not the only route by which impulses are trans- 
mitted. Charpentier says the influence of the spinal cord over uterine 
contractions cannot be denied, for in women who have paralysis, uterine 
contractions, if less painful, are also very feeble, and if a few such had 
easy deliveries, yet in the majority labor is tedious from feeble uterine 
contractions. Besides the centres just mentioned, Dembo found collec- 
tions of ganglionic cells between the peritoneal and the muscular walls 
of the uterus and groups of cells lying in the anterior vaginal wall which 
he believes to be uterine motor centres. Jewett reports a case in which 
after a Cseso-hysterectomy the uterus, which was totally relaxed at the 
moment of amputation, contracted to a hard globe shortly after its re- 
moval from the abdomen. 

Thus there are three motor centres which may give rise to contrac- 
tions of the uterus — a centre in the medulla, the cervical ganglion, 
and a collection of ganglia in the anterior walls of the vagina and in 
the Avails of the uterus. Of the relative importance of these centres we 
have no definite knowledge. 

A great many theories have been advanced to account for the onset of 
labor, but none of them are entirely satisfactory, since none apply to all 
cases. All we can say at present is that labor is not the result of any 
one, but is due to the concurrent operation of a number of causes. These 
act by inducing uterine contractions, or perhaps it would be better to 
say by increasing the painless rhythmic contractions which are present 
in marked degree throughout the entire period of pregnancy. Among 
the probable causes of the active uterine contractions of labor the most 
important are the following: 

1. Loosening attachment of the ovum, converting it into a foreign 
body. 

2. Excess of carbon dioxide in the blood. 

13 



194 PHYSIOLOGY OF LABOR. 

3. Distention of the uterus by the growing ovum. 

4. Mental impressions. 

1. Loosening Attachment of the Ovum. Separation of the decidua vera 
begins with the first active contractions of the uterus. The separation 
may be the result of a number of contributing factors; for example, 
fatty degeneration of the decidua has been observed in the latter part of 
pregnancy ; but this is not constantly found. Simpson held that it 
occurred in the fourth month of pregnancy. 

The decidua vera is divided into two parts. One part consists of an 
outer, dense, membranous layer of large cells resembling pavement epithe- 
lium; the other part, of a layer of much looser texture in which are found 
the large decidual glands. It is in this spongy layer that the separation 
of the decidua takes place. In this layer toward the end of pregnancy 
the trabecule enclosing the spaces of the network have been observed 
to decrease in size from jfa of an inch to 25 1 00 of an inch. The layer 
seems to shrivel and thus to permit easy separation. The occurrence 
of hemorrhages, the result of the compression and tearing caused by the 
violent uterine action, also tends to detach the ovum from the walls of 
the uterus, and may act to intensify the pains already established. This 
separation of the decidua from the uterine wall makes the ovum in part 
a foreign body, and this explains the continuance of the expulsive efforts. 

2. Excess of Carbon Dioxide in the Blood. Brown-Sequard has shown 
that excess of carbon dioxide in the blood of pregnant animals will 
bring on uterine contractions. This effect may be produced directly 
or through the uterine motor centre. As the foetus grows, it demands 
more nutriment, and there must be a corresponding increase of the 
products of tissue waste, including carbon dioxide. The presence of 
carbon dioxide in the blood of the placenta is accounted for in several 
ways, but many of the explanations agree in this, that it is the result 
of some interference with the passage of the blood through the pla- 
centa. Leopold and Ruge believe it to be due to the formation of 
thrombi in the placenta. Friecllander explains the formation of blood 
coagula in this organ by the penetration into the uterine sinuses of the 
cells that form in the serotina about the eighth month. Another ex- 
planation of the increase of the carbon dioxide is based on the fact that 
the trabecuke of the sinuses are observed to decrease until, at the end 
of pregnancy, they are about one-fifth their former size. This may be 
the result of cell infiltration of the Avails and consequent contraction. 
When the venous blood has accumulated to a certain amount the con- 
tained carbon dioxide stimulates the uterine contractions, and labor is 
established. 

3. Distention of the Uterus. The growth of the gravid uterus is a 
result in part of development of the uterine muscularis, in part of dis- 
tention of the uterine parietes. There is not only hypertrophy and hyper- 
plasia, but as well, it is assumed, a rearrangement of the muscular fibres, 
so that, instead of lying side by side, they are disposed more nearly end 
to end. When the limit is reached and growth and extension can go on 
no further, then labor begins. 

Power likened the evacuation of the uterus to the emptying of viscera 
such as the bladder and the rectum. These permit distention to a certain 
extent and then expel their contents. 



MECHANISM AND CLINICAL COURSE OF NORMAL LABOR. 195 

4. Mental Impressions. It is only necessary to mention the effect of 
great grief as an etiological factor in abortion to call to mind how im- 
portant a part the emotions may play in inducing labor. But such 
agencies as these and slight muscular strains, jars, and falls happening 
at the close of gestation, and the descent of the foetus low in the pelvis, 
due to yielding of the cervix, cannot be viewed as essential causes of the 
onset of labor. The establishment of labor is often wholly independent 
of such influences. 

In the existing state of our knowledge it is impossible to say which 
of the many possible causes are most active in bringing about the final 
result. 

The Clinical Phenomena of Beginning Labor. 

The more important phenomena of labor are those which pertain to 
the uterus. These will next be considered. 

Labor Pains. Contractions of the uterus occurring during labor are 
known in all languages by the word which expresses pain. Labors un- 
attended with pain have been recorded, but they are exceedingly rare. It 
is also said that patients have been delivered in a condition of hypnotic 
sleep, but such experiences are among the rarer curiosities of obstetric 
practice. The cause of the painful sensations in the early part of labor 
is the distention of the cervix, and in the latter part the suffering is 
due to stretching of the vagina and vulva and to compression of the 
nerve-trunks in the pelvis. 

Bearing in mind that the uterine musculature is a collection of non- 
striated muscular fibres, it may be expected to manifest the same kind 
of activity that is observed in this variety of muscular tissue in other 
parts of the body. 

The contractions are involuntary. The patient cannot initiate them 
nor can she stop them when they have begun, although in the stage of 
expulsion she can assist them by voluntarily bringing the abdominal 
muscles into play. Notwithstanding the automatic character of the 
uterine contractions, mental impressions may affect them in a marked 
degree; for example, the arrival of the physician may retard, and even 
for a short time arrest, the labor. The pains are likely to be inhibited, 
too, by the reflex effect of a full bladder or rectum. 

The pains are intermittent, and the interval between them varies with 
the stage of progress. The intervals of repose grow shorter as the labor 
progresses, until finally, at the end of the second stage, the expulsive 
efforts are almost continuous. The intermittent character of the pains 
is essential to the safety of the foetus. During the height of a uterine 
contraction the placental circulation is almost wholly interrupted, and 
the foetus, moreover, suffers powerful compression. Under persistent 
uterine contraction it would soon perish. 

The contractions are peristaltic, proceeding from one extremity of the 
uterus to the other. The direction of this contraction wave is from 
fundus to cervix. In some of the lower animals contractions have been 
observed to pass from cervix to fundus, but such phenomena are doubt- 
less exceptional and abnormal. The wave is said to last from one-third 
to two-thirds the length of the labor pain. Assuming that the average 



196 



PHYSIOLOGY OF LAB OB. 



duration of a pain is one minute, the peristaltic wave would last from 
twenty to forty seconds. 

The Mechanism of Dilatation. 

Upper and Lower Uterine Segments. The gravid, like the non-gravid 
uterus, presents two general divisions, the body and the cervix. The 
body of the parturient uterus, however, resolves itself into two parts, 
designated respectively the upper and the lower uterine segment. The 
plane which separates the two segments lies nearly at the level of the 
utero-vesical fold of peritoneum. This plane represents the level at 
which the conical lower portion of the cavity begins to be smaller than 
the greatest sectional plane of the foetal head which must pass through 
it. The lower uterine segment, therefore, comprises all that portion of 
the body of the uterus which, together with the cervix, must undergo 
dilatation preparatory to the expulsion of the foetus. The upper uterine 
segment includes approximately the upper two-thirds of the entire 
length of the uterus; the lower segment and the cervix, which are of 
nearly equal lengths at the beginning of labor, constitute the remaining 
third] Fig. 179. 

Fig. 179. 




CE. Contraction ring, or retraction ring, at onset of labor, oi. Os internum, oe. Os externum. 

(SCHROEDER.) 

Uterine Retraction. During labor the expellent force obviously must 
be supplied by the contractions of the upper uterine segment. The 
lower segment is concerned in dilatation, and after dilatation is fully 
established it has become entirely passive. The dilatation which takes 



MECHANISM AND CLINICAL COURSE OF NORMAL LABOR. 197 

place in the cervix and the lower uterine segment as the upper segment 
contracts is a phenomenon somewhat comparable to what occurs in other 
hollow viscera during the expulsion of their contents. It is in part a 
relaxation and in part the result of distention. 

Fig. 180. 




Retraction ring at end of first stage of labor. Lower birth canal consists of the lower uterine 

segment and the cervix. (Schroeder.) 

oe. Os externum, ox. Internum. CR. Contraction or retraction ring. 

After labor is established the musculature of the upper uterine seg- 
ment becomes thickened, and that of the lower segment as it dilates is 
correspondingly thinned. The line of demarcation between the thickened 
upper and the thinned lower segment presents a ridge which often may 
be made out on palpation over the abdomen during a pain. Fig. 180. 

This ridge is called the ring of Bandl, from the name of the authority 
who first described it. It is also known as the contraction or the 
retraction ring. The latter is, perhaps, the preferable term. The situ- 
ation of the retraction -ring, which at the onset of labor is below the 
pelvic brim, rises higher as the pains go on, and in abnormally long or 
obstructed labors may reach nearly the level of the navel. The term 
retraction applies to the process by which the thickening takes place in 
the upper segment. It is due mainly, if not wholly, to persistent short- 
ening and thickening of the muscular fibres. While the shortening of 
the muscular fibres which occurs during the uterine contractions is 
followed by elongation in the intervals, the primal length is not fully 
restored. It is commonly taught that retraction is due in part also to 
a rearrangement of the muscular fibres. Fibres, it is assumed, which 



198 PHYSIOLOGY OF LABOR. 

at the beginning of labor lie nearly end-to-end, in course of retraction, 
come to lie nearly side by side. The retraction of the upper segment 
of the uterus increases as the volume of its contents is diminished. The 
retraction, in other words, progresses in proportion to the progress of 
the birth and the upward movement of the retraction-ring. 

Dilatation of the Cervix. In the dilatation of the cervix three agencies 
are concerned: 

1. Softening of the cervical tissues. 

2. The hydrostatic pressure of the bag of waters. 

3. The contraction of the longitudinal fibres of the upper uterine 
segment. 

1. Progressive softening of the cervix, commencing below and 
extending upward, is normally present from the early months of preg- 
nancy, and is a valuable sign of this condition. Contractions of the 
uterus, by interfering with the return circulation, cause over-distention 
of the cervical veins and lymphatics, and there is an infiltration of the 
tissues with serous exudate; at the onset of labor the infiltration and 
softening increase rapidly. 

The yielding of the cervix in the first stage of labor is doubtless in 
part a physiological relaxation analogous to that which takes place in 
sphincter muscles. 

2. Hydrostatic Pressure of the Bag of Waters. The second 
agency in securing dilatation — pressure from the bag of waters — is a 
very important one. Its value is most clearly brought to our attention 
when we have lost it. If, by mischance, early rupture of the mem- 
branes has occurred, and the waters have drained away, the labor is 
termed a dry labor. Such labors are proverbially liable to be of long 
duration and may be prejudicial to mother and child. 

During a uterine contraction, as the cervix opens, the lower portion 
of the membranes, loosened from its attachment by the first active uterine 
contractions, insinuates itself into the opening. Since the fluid within 
the membranes transmits the force of the uterine contraction equally in 
all directions, the bag of waters is distended laterally as well as down- 
ward, exerting an expansive pressure directly upon the walls of the 
cervix. The lateral expanding force acts in the radii of the resisting 
ring. Other things being equal, the hydrostatic pressure increases with 
the area of the surface on which it acts. The dilating force becomes 
greater, therefore, in proportion as the dilatation progresses. Fig. 180. 

With premature rupture of the membranes we lose the efficient 
hydrostatic wedge, and have in its place the head. This substitutes a 
body almost unyielding in its nature for the water-bag. The former 
is inferior in dilating power to the equable hydrostatic pressure of the 
bag of waters, but moulding and the caput succedaneum, yet to be 
described, add somewhat to the sharpness of the dilating wedge. They 
compensate in some degree for the loss of the hydrostatic pressure of the 
sac of waters. 

3. Action of the Longitudinal Muscular Fibres of the 
Uterus. While the membranes are unruptured the contents of the 
uterus are practically incompressible. We may imagine a uterus con- 
taining an absolutely incompressible body of a similar shape to the ovum. 
It is obvious that the pull of the contracting longitudinal muscular fibres 



MECHANISM AND CLINICAL COURSE OF NORMAL LABOR. 199 

of the upper uterine segment will act to drag the lower segment and 
cervix upward over the contained body. The oblique muscular bundles 
act in some degree with like effect. It must be remembered, too, that 
the circular bundles are not so strong in the cervix as in the fundus. 
The muscular structure of the lower segment is thinner and weaker than 
that of the upper segment. 

Fig. 181. 




Bag of waters during a pain. 



Another explanation of the dilating mechanism which has been offered 
is the following: AVhen a wave of contraction passes from one end of 
the uterus to the other, it must pass through the length of the longi- 
tudinal fibres and across the circular fibres. It is suggested that the con- 
traction wave traverses the longitudinal fibres more rapidly than it affects 
the circular fibres. If this is true, the wave passing through the longi- 
tudinal fibres would reach the cervix before that affecting the circular 
fibres, and would draw the cervix over the presenting part while the 
circular fibres of the lower segment are at rest. 

The Cervical Rings. The first effects of the dilating force are observed 
at the internal os. This expands with the pains, and for a time con- 
tracts again in the intervals. As the dilatation progresses the os in- 
ternum becomes permanently relaxed. A digital examination at this 
time reveals two distinct resisting rings, one at the external and one at 
the internal end of the cervical canal. The canal itself preserves a 
pronounced fusiform shape. Later, the os internum becomes perma- 
nently obliterated, having merged into the lower uterine segment. The 
ovum from this time rests upon the external ring or the os externum. 
This is gradually expanded as the labor goes on, till finally the walls of 
the dilated utero-cervical zone and those of the vagina form one continu- 
ous canal, with a barely perceptible interruption at the external ring of 
the cervix uteri. 



200 PHYSIOLOGY OF LABOR. 

Retraction of the Pubic Segment of the Pelvic Floor. Toward the close of 
the first stage and during the earlier part of the second, as the cervix 
is drawn upward over the head, the bladder is lifted partly above the 
pubic bone by the traction of the longitudinal muscular fibres of the 
uterus. The bladder is thus in some measure protected from injury by 
the pressure of the head as it traverses the pelvic canal. 

The Clinical Phenomena of the First Stage. 

The Pains. The patient realizes that she is in labor when she begins 
to suffer regularly recurring pains in the back. From this region the 
pains may radiate around to the front and, perhaps, be felt running 
down the thighs. 

The initial labor pains most frequently come on in the early part of 
the night. They at first recur at intervals of about thirty minutes, but 
as the labor goes on the intervals become progressively shorter. 

The pains differ little in character from the so-called false pains fre- 
quently experienced during the later weeks of pregnancy, but they are 
distinguished by a more or less rhythmical recurrence and by growing 
strength and frequency. 

The painful character of the uterine contractions of labor is probably 
due in great part to the stretching of the cervix. The pains are sharp 
and " nagging." The patient walks restlessly about the room, sits in a 
chair, or at times takes to the bed. If she is on her feet when a con- 
traction begins, she bends over a chair or other object near at hand. 
Her face during the pains is congested, owing to fixation of the respira- 
tory muscles. Reflex vomiting is not infrequent as the dilatation becomes 
nearly complete. Its occurrence may usually be taken as evidence that 
the first stage of labor is well advanced. 

The uterine contraction of labor presents three stages — a period of 
increase, a period of acme, and a period of decrease. The stage of acme 
lasts longer than the other stages, and the increase is longer than the 
decrease. The length of the acme differs somewhat at different stages 
of labor. 

The force of the contraction has been estimated by different methods, 
none of which is entirely satisfactory. Attempts have been made to 
estimate the stress necessary to rupture the membranes, and, by placing a 
bag of water in the uterus in front of the advancing head, to determine 
how much tension is sustained by the contents of the bag during 
a pain. According to Duncan and Poppel, the membranes rupture 
under a pressure ranging between four and thirty-seven and a half 
pounds. Schatz, by the aid of a manometer, estimated the resistance 
overcome by the advancing head to be between seventeen and fifty-five 
pounds. We have as yet, however, no reliable means of determining 
the force exerted in expelling the child. 

The degree of pain is variable. The pains of dilatation are often not 
so well borne as those that come later, because the parturient is impatient 
of suffering which seemingly results in no progress. The pain caused 
by the passage of the head over the pelvic floor, if not relieved by an 
anaesthetic, is usually the most intense. 

The Show. By expansion of the cervix and the lower uterine segment, 



MECHANISM AND CLINICAL COURSE OF NORMAL LABOR. 201 

the membranes in the lower part of the uterus are separated from the 
uteriue wall, causing a slight discharge of blood known as the show. 

The cervical and the vaginal secretions become more profuse as labor 
is established. They serve as a lubricant to the passages in preparation 
for the expulsion of the foetus. 

The irritability of the bladder and the rectum already established by the 
lightening, is increased when active pains begin. Urinary and fecal 
evacuations occur more frequently than before. 

The cervix becomes thin and sharply defined during the pains. In 
multipara? the lower part of the cervix is more patulous, and offers less 
resistance to the advancing bag of membranes than in primipane. 

The Pulse. The maternal pulse becomes more rapid during a pain; 
the heart-tones of the foetus are less distinctly audible, and the pulse-rate 
is slower than in the intervals. The fall in the foetal pulse-rate is due 
to increased vascular tension caused by the compression to which the 
foetal mass is subjected during a uterine contraction. 

Rupture of the Bag of Waters. When the cervix has become well 
dilated, rupture of the membranes may occur. It may take place at an 
earlier period, or may not happen till the end of the stage of expulsion. 
Very rarely a full-term child may be born with the membranes unbroken. 

Rupture of the bag of waters is announced by a gush of water from 
the vagina. The quantity of liquor amnii expelled will depend on the 
extent to which the lower uterine segment is occluded by the presenting 
part. It is not always safe to rely on the patient's statement that the 
membranes have ruptured. She may be misled by leakage of urine 
from the bladder. If the discharge is due to rupture of the membranes 
there is usually more of it between than during the pains, since the head 
then recedes and allows the waters to escape. Sometimes an accumula- 
tion of fluid has taken place between the amnion and chorion, and this 
may escape by rupture of the chorion, the amnion still remaining intact. 
It is claimed that amnial liquor may transude through the unbroken 
membranes. 

Emotional Influences. The progress of the labor in this stage is easily 
influenced by emotional causes. The presence of a strange face or the 
narration of the horrors of previous cases by friends or by the nurse may 
stop the pains for a long time. After the membranes give way the uterus 
retracts as the waters escape, and the pains are resumed with new vigor. 

The bearing of the patient differs greatly in different women; some 
apparently suffer very little, and others complain bitterly. 

The Mechanism of Expulsion. 

The " mechanism of the second stage of labor" concerns especially 
the movements which the foetal head and the trunk undergo in course of 
thei v I isit through the birth-canal. Since the head-diameters are 
large less compressible than are those of the trunk, tho mechanism 

is most important as relates to the head. 

1. The head movements are : Descent, flexion, rotation, extension, 
restitution, external rotation. 

Descent. During the first stage of labor, as has been seen, the force 
of the uteriue contractions is expended in dilating the utero-cervical 



202 



PHYSIOLOGY OF LABOR. 



Fig. 182. 



zone. At the beginning of labor, if the membranes are intact, the 
intra-uterine pressure developed by a uterine contraction is, in accord- 
ance with the familiar law of hydrostatics, brought to bear upon the 
foetus equally in all directions. After partial dilatation of the cervix 
and the formation of the bag of waters the head sinks into and partially 
occludes the lower uterine segment. Under the pressure developed in 
the hind waters during a uterine contraction the head advances as the sac 
of fore waters protrudes. After the membranes rupture the head descends 
with a moving force which is measured by the propelling power less the 
resistance opposed by the birth-canal. 

So long as the waters have not all escaped, the expellent force is trans- 
mitted to the head, in part, sometimes wholly, through the liquor amnii. 
After the waters have drained away the foetal parts are consolidated in 
a compact mass by the grasp of the uterus, and, the fundus contracting 
directly upon the breech, the propelling force is transmitted in great 
measure through the entire foetal ellipse. The lateral compression 
exerted by the uterine contractions acts to steady the foetal mass and 
adds also somewhat to the extruding force. 

Flexion. Flexion is in part primary, being the normal posture of the 
foetus in utero. It is increased when the head begins to encounter the 

resistance of the lower uterine segment, 
and becomes complete after engagement 
in the bony pelvis. The mechanism is 
as follows: The head is so attached to 
the trunk that its sincipital is longer than 
its occipital pole. The head, in other 
words, corresponds to a lever of unequal 
arms, the occipito-atlantoid articulation 
being the pivotal point and the sincipital 
arm the longer arm of the lever. Fig. 181. 
When the head begins to encounter the re- 
sistance of the birth-canal this resistance, 
even though equal at the two poles, must 
act with greater effect on the long arm of 
the lever. This advantage in normal con- 
ditions is increased by the primary flexion. 
The chin, therefore, dips toward the ster- 
num. The flexion is increased as the op- 
posing forces increase, and becomes com- 
plete when the head meets the resistance 
of the bony walls of the pelvis. 

Another factor in bringing about the 
flexion of the head is to be found in the 
tendency of the cephalic ellipsoid to adapt 
itself to the shape of the car 1 th rough 
illustrating the different lengths of which it descends. Under the isure 
the frontal jirm, fb, and the occipital f the pelvic walls the long ax : naturally 

falls into relation with the axis of the 
birth-canal. 

The advantage of flexion is obvious. It brings the smallest, or sub- 
occipito-bregmatic, circumference of the head in relation with the irdle 
of resistance in place of the larger occipito-frontal circumfe i 




arm. B O, of the lever presented by the 
foetal head. 



MECHANISM AND CLINICAL COURSE OF NORMAL LABOR. 203 

As has been stated, the head enters the brim fully flexed, or it soon 
becomes so under normal circumstances; thus all motion iu an antero- 
posterior direction is checked, but some degree of lateral mobility still 
remains. A great deal of discussion has arisen with reference to the 
question whether the head inclines laterally to one side or the other 
during its passage through the brim. Naegele and Dubois hold that 
the anterior parietal bone dips deeper in the pelvis than the poste- 
rior, bringing the sagittal suture nearer to the promontory than to the 
symphysis. This lateral obliquity of the head is termed asynclitism. 
When the head descends with its planes parallel to those of the pelvis 
the descent is said to be synclitic. Kiineke and most other authorities 
believe that synclitism is preserved till delivery takes place. In labor in 
deformed pelves the obliquity of Naegele is present in some degree. 

Rotation. When the head reaches the pelvic floor the long diameter 
of the head which passed the brim in a direction parallel with the oblique 
diameter of the pelvis begins to turn till at the moment of expulsion it 
is nearly parallel with the antero-posterior diameter of the pelvis, the 
occiput normally swinging to the front. 

The chief agency in bringing about the rotation of the head as it tra- 
verses the pelvis is the action of the pelvic floor. The floor of the pelvis 
may be considered as made up of two lateral halves, each of which slopes 
downward, inward, and forward. That pole of the fcetal head which 
lauds first on one lateral half of the floor glides downward, inward, and 
forward, and emerges from the outlet beneath the pubic arch. When the 
head is normally flexed the occipital pole first reaches the floor of the pelvis, 
and, as it descends, is rotated inward to escape under the arch of the pubes. 

It will be noted that flexion is a prerequisite to rotation. It is only 
when the occipital pole of the head dips lower in the pelvis than the sin- 
cipital that anterior rotation of the occiput is likely to prevail. Should the 
sinciput reach the pelvic floor at the same time as the occiput the former 
may be rotated forward under the symphysis, the latter going backward 
into the hollow of the sacrum. 

The influence of the planes or grooves of the bony pelvis, on which 
stress has been laid by certain obstetric writers, is of secondary importance 
in effecting rotation of the head. That the action of the pelvic floor is 
the principal agency in causing rotation would seem to be sufficiently 
established by the experiment of Dubois. Dubois showed that when 
the head of a foetus is pushed through the pelvis of a woman who had 
died before or immediately after delivery, no matter in what position 
we place the occiput, if it strikes the pelvic floor in advance of the 
sinciput, it will turn forward, provided the floor has not been injured by 
rupture or overstretching. The repetition of the experiment will, if 
too often repeated, overstretch the floor and then rotation will fail. 

Edgar, of New York, screwed a swivel into the head of a foetus half 
an inch behind the small fontanelle. Attaching a cord to the ring of 
the swivel, he repeatedly dragged the head through the pelvis of a womau 
dead after recent delivery. The occiput invariably rotated to the front, 
even when the head entered the pelvis in occipito-posterior position, so 
long as the pelvic floor retained its integrity. When the tonicity of the 
floor became impaired by overstretching, the head traversed the pelvis 
in very nearly the same position as it had entered. 



204 



PHYSIOLOGY OF LABOR. 



After the leading pole begins to pass the lower end of the symphysis 
its forward rotation is favored by the fact that this direction is that of 
least resistance. 



Fig. 183. 




Beginning distention of pelvic floor. (Farabeuf and Varnier.) 
Fig. 184. 




Beginning extension of head. (Farabeuf and Varnier.) 

Extension. By the time the occiput is about to emerge under the pubic 
arch the sinciput rests firmly upon the coccyx and lower portion of the 
sacrum. The biparietal diameter lies in the grasp of the ischial tuber- 
osities and the vertex distends the pelvic floor. Fig. 183. The long 
diameter of the head lies nearly in line with the sacro-pubic diameter of 
the pelvis. 



MECHANISM AND CLINICAL COURSE OF NORMAL LABOR. 205 

As the head is driven down the distention of the pelvic floor is 
increased. The floor grows progressively thinner as it stretches under 
the pressure of the advancing head, and becomes more and more 
elongated antero-posteriorly till at the moment of expulsion the length 
of the sacral segment, from coccyx to the posterior edge of the vulva, 
is 6 inches. 



Fig. 1 




Maximum distention of pelvic floor. Equator of head about to pass. (Farabeuf and Varniee.) 




Occiput rides up in front of symphysis. Pelvic floor retracts. (Farabeuf and Varnier.) 

As the occiput escapes under the arch of the pubes it rides up in front 
of the symphysis till the nucha rests against the subpubic ligament. 
The head is then expelled mainly by descent in the line of the birth- 
canal, partly at the last moment by a movement of extension, the 
vertex, the forehead, and the face successively sweeping over the free 
edge of the sacral segment of the pelvic floor. Figs. 184, 185, and 186. 



206 



PHYSIOLOGY OF LAB OB. 



Throughout its descent the head advances with the pains and recedes 
in the intervals. In normal conditions this alternate advance and 
recession continues during expulsion till the head is well in the grasp 
of the vulvo-vaginal ring. From this time no recession takes place 
between the pains. 

Restitution. The rotation of the head in course of its transit through 
the pelvis develops a certain degree of torsion of the neck. As the head 
is expelled the neck untwists. The head, therefore, immediately it is 
born, assumes a position corresponding to that in which it had entered 
the pelvis. This movement is termed restitution. It is of interest for 
the reason that it indicates the primary position of the head. Fig. 187. 

Fig. 187. 




Foetal head after restitution in L. O. A. position. Shows also caput succedaneum. iRibemoxt- 

Dessaignes and Lepage.) 

External Rotation. The shoulders descend in the oblique diameter of 
the pelvis opposite that in which the head came down. They rotate, 
therefore, in a direction opposite that which the head had pursued. 
Rotation of the head is accordingly continued during the expulsion of 
the shoulders and in the same direction as that which obtained in the 
movement of restitution. This supplementary rotation is termed ex- 
ternal rotation. 

Delivery of the Trunk. The shoulders engage in the oblique diameter 
of the pelvis opposite that in which the head entered. They rotate less 
perfectly than the head. The anterior shoulder is arrested behind the 
symphysis and the posterior shoulder rides over the pelvic floor and, as 
a rule, first appears at the vulva. After expulsion of the posterior, the 
anterior shoulder is disengaged and escapes. The breech undergoes only 
partial rotation. As the trunk is expelled it is followed by a gush of 
bloody water. 

Clinical Phenomena of the Second Stage. 

If the patient is very much fatigued from a long first stage she may 
sleep between the pains. These brief periods of rest help to renew her 



MECHANISM AND CLINICAL COURSE OF NORMAL LABOR. 207 

strength and add to the efficiency of the pains. The parturient is much 
more likely to sleep if chloral has been administered in the first stage. 

The pains are more severe during the stage of expulsion, but the 
patient realizes with a sense of satisfaction that the head advances with 
the pains, and the hope of speedy relief fortifies her endurance. 

When the occiput has reached the pelvic floor, the cavity of the pelvis 
is completely filled and the pressure of the head gives rise to marked 
rectal tenesmus. The sphincter ani becomes relaxed and one or more 
fecal evacuations usually take place as the head passes over the floor of 
the pelvis. The contractions of the abdominal muscles toward the close 
of the expulsive stage are reflex and wholly involuntary. As the head 
distends the vulvar ring the pains become so intense as sometimes to 
result in transient delirium. 

A brief pause ensues on birth of the head. After a moment or two 
of rest, contractions recur and the shoulders pass ; then the body, fol- 
lowed by a gush of bloody amniotic fluid, is expelled. 

The second stage is now ended, and a period of a few moments follows 
before the pains are again renewed to expel the afterbirth. 

Moulding of the Head. Even in typical normal labors, the head under- 
goes more or less alteration in shape as it is driven into the pelvic brim. 
This is an important fact in the mechanism of labor, since it conduces 
in marked degree to the adaptation of head to pelvis. 

Under the influence of the pelvic pressure forces the diameters in the 
grasp of the resisting girdle are all reduced, this reduction being compen- 
sated by elongation of the cephalic mass in the direction of the birth-canal. 
The engaging diameters are thus diminished to the average extent of 
6 mm., J inch. The degree of moulding will obviously depend on the 
relative size of head and pelvis and the plasticity of the cranial vault. 
The plasticity varies with the extent of ossification, which is not abso- 
lutely constant at the same stage of development. 

Moulding is an essential element in the mechanism of the expulsive 
stage of labor not only by reason of adaptation of head to pelvis, but 
also because elongation of the head favors normal rotation by increasing 
the dip of the leading pole. 

Caput Succedaneum. The caput succedaneum is an oedematous swell- 
ing which is developed on the presenting part in course of the birth. It 
is formed after rupture of the membranes. During a uterine contraction 
all parts of the foetal mass are under pressure except that which offers 
to the examining finger within the girdle of resistance. The vessels of 
the presenting part become engorged during the pains and a serous 
exudate takes place into the cellular tissues of that portion of the foetal 
surface. See Fig. 187. 

The size of the caput succedaneum will obviously vary with the 
degree of force which produces it. It is large, therefore, in prolonged 
and difficult labors. Its size affords a valuable sign in the vaginal 
examination of the degree of obstruction which the foetus encounters in 
its passage through the pelvis. 

The location of the caput succedaneum is of interest in the examina- 
tion of the head after delivery as indicating the position in which the 
head had descended. In anterior positions it is situated at the posterior, 
and in posterior positions on the anterior aspect of the summit of the 



208 PHYSIOLOGY OF LABOR. 

head. In left positions it occurs to the right, and in right positions to 
the left of the median line. A right occipito-posterior location of the 
caput, therefore, indicates a left occipitoanterior position of the head, 
and so on. 

It should be remembered that the situation of the tumor may be 
modified when the head has been subjected to long-continued pressure 
in the lower portion of the birth-canal after partial rotation had taken 
place. 

The caput, like moulding, by adding to the elongation of the leading 
pole of the head, promotes rotation. In labors in which the head 
furnishes the dilating wedge it adds to the efficiency of the dilator by 
increasing the acuteness of the wedge. 

A similar swelling develops on the presenting part in other than 
cephalic presentations. To this it is customary to apply the same term 
on whatever part of the foetal surface it occurs. The tumor usually 
disappears within twenty-four hours after birth. 

The Mechanism of Placental Expulsion. 

After expulsion of the child the uterus grows smaller by retraction 
and closes about the placenta. When active contractions are again 
resumed the placenta is gradually detached. As the seat of placental 
attachment shrinks during a uterine contraction, the placenta not being 
sufficiently retractile to accommodate itself fully to the diminished area 
of the placental site, it is partially torn from the uterine wall with each 
pain. Rarely it may happen that the placenta is wholly separated by 
the first strong contraction. The placenta will then probably be forced 
out folded on itself from side to side, presenting by its edge. 

If the placenta is not wholly detached at the first expulsive efforts, a 
different mechanism may obtain. Detachment sometimes takes place 
first over the central portion of the placental seat. Then, as the uterus 
relaxes, a retro-placental blood clot is formed. With each succeeding con- 
traction the area of detachment is increased and the clot grows accord- 
ingly. The liberated portion of the placenta is thus thrust downward 
toward the cervical opening and the afterbirth is expelled flatwise by its 
amniotic surface. 

When it is extruded, with its edge presenting, the grasp of the uterus 
acts directly upon the placenta. When it is dissected off by the blood 
clot its expulsion is partly due to the extruding force propagated through 
the retro-placental blood clot during the uterine contractions. Figs. 
188 and 189. 

The membranes are last to be detached. In either method of expul- 
sion the placenta is thrust downward through the rent in the membranes 
and the latter are peeled off by traction of the placenta. 

It is obvious that the passage of the placenta with its long diameter 
corresponding to the long diameter of the uterus is most favorable to 
easy expulsion. 

Persistent adhesion of the membranes may prevent the placenta from 
being delivered with its long diameter in conformity with the long 
diameter of the uterus. Pulling on the cord, by pulling down the 
central portion of the placenta, may act with like effect. 



MECHANISM AND CLINICAL COURSE OF NORMAL LABOR. 209 

Fig. 188. 





Showing the two methods of placental expulsion. (Schroeder.) 

The Clinical Phenomena of the Third Stage. 

At a variable length of time after the child has been delivered the 
uterus again commences to contract, the placenta is gradually forced 
into the vagina, and, when the muscular tonicity of the pelvic floor has 
not been too much impaired, may be expelled from the vulvar orifice. 
The membranes are dragged after it, sometimes promptly, sometimes 
peeling slowly from their uterine attachment. 

The expulsion of the placenta is accompanied with a greater or less 
amount of clotted and of liquid blood. The total quantity of blood 
lost during the third stage, together with that expelled at the birth of 
the child, should not, in strictly normal conditions, exceed a pint. 

After-pains. After the expulsion of the placenta there is a pause of 
variable length in the uterine contractions. The contractions of this 
period are termed after-pains. They are not usually painful in primi- 
parae. In multipara they are frequently violent enough to cause con- 
siderable distress. Severe after-pains are due, as a rule, to the retention 
of blood-clots in the uterus. This occurs more frequently in women 
who have borne children, owing to the greater relaxation of the multi- 
parous uterus. In the presence of clots the uterine contractions become 
more powerful in the effort to expel them. 

Retraction of the Uterus. Normally the after-pains serve a useful 
purpose. They bring about retraction, by which the active contractile 
portion of the uterus becomes shorter and thicker. The vessels, which 

14 



210 PHYSIOLOGY OF LABOR. 

are intimately interwoven with the muscular bundles, are thus securely 
ligated. 

The peritoneal covering of the uterus accommodates itself to the 
diminished volume of the organ by reason of its elasticity. The uterine 
peritoneum presents no loose folds, as a rule, even after complete re- 
traction. 

Situation of the Uterus. On examination over the abdomen at the 
close of labor, the fundus is felt about half-way from pubes to umbilicus; 
normally it becomes as hard as a billiard ball during after-paius, relax- 
ing only partially in the intervals. 

Lower Uterine Segment. The lower uterine segment and the cervix 
remain passive for several hours after labor. The cervix presents a 
soft and almost shapeless mass scarcely distinguishable by the touch 
from the loose vaginal folds. Within a few hours the tonicity of its 
muscular structures begins to be re-established and the cervix to resume 
its usual shape. 



CHAPTER IX. 

THE MANAGEMENT OF NORMAL LABOR. 

PREPARATORY TREATMENT. 

Xo more important duties devolve upon the obstetrician than those per- 
taining to the observation and care of his patient in preparation for labor. 
Until recent years this part of his responsibility was too often overlooked. 
Happily, to-day the necessity for prophylaxis against the possible ills and 
accidents of childbed is generally recognized. The enforcement of hygi- 
enic rules, the regulation of the health and habits of the patient during 
pregnancy, is vital to the successful conduct of the obstetric case. Even 
minor departures from the normal course of gestation should receive 
the attention of the physician and, as far as possible, be corrected. Es- 
pecially ought he to inform himself in advance of the relative size of 
head and pelvis, of the presentation and position of the child, and, if 
possible, of all the facts of the individual case which may bear upon the 
issue of the labor. 

Urinary Examinations. The excretory activity of the kidneys should 
be watched from the first. It is a good general rule to examine the 
urine at least once monthly during the first six months, and twice or 
more during the seventh. In the last two months of gestation system- 
atic examinations should be made weekly. The patient may be requested 
to report to her physician from time to time the daily quantity of urine. 
Toxic conditions can seldom occur in a patient who is voiding sixty 
ounces or more daily. The physician should not trust to a mere test 
for albumin. Albuminuria is not necessarily attended with marked 
toxaemia, nor is grave toxaemia in pregnant women always associated 
with albuminuria. Most essential are systematic quantitative deter- 
minations of the urinary solids. Especially significant is the daily 
excretion of urea. Though this particular solid is not a prominent 
factor in the toxaemia of pregnancy, the quantity of urea affords a 
fairly reliable index of the eliminative activity of the kidneys. It 
should not be forgotten, however, that the amount of urea and of the 
total urinary solids will vary with the character and quantity of food 
ingested and from other causes. The general condition of the patient 
should be taken into account as well as the urinary findings. 

Tests for Albumin. For clinical use a good test for albumin is Esbach' s. 
The reagent consists of picric acid, 10 grammes; citric acid, 20 grammes; 
water, 1000 grammes. The urine is mixed in a test-tube with an equal 
volume of the test solution. Heat and nitric acid, nitric acid cold by 
the contact method, or Tanret's test, with suitable precautions, are con- 
venient and reliable tests for albumin. 

Urinary Solids. One of the ready methods of computing the daily 
quantity of urinary solids is that of Haines, which is as follows: Multi- 
ply the last two figures in the number representing the specific gravity 

211 



212 



PHYSIOLOGY OF LABOR. 



Fig. 189. 



Fig. 190. 



by the number of ounces of urine voided in twenty-four hours, and the 
resulting product by 1^. This gives approximately the number of 
grains of solid matter in the given volume of urine. The average 
amount of solids in health, it will be remembered, is 1000 grains. 

Urea. For the estimation of urea the following method from Bart- 
ley's Chemistry is recommended: "A graduated tube (Fig. 189) is filled 
to the fifth division with a 20 per cent, aqueous solution of potassic 
bromide. Chlorinated soda solution (Squibb) is then added to the 
fifteenth or twentieth division. Pure water to the depth of one inch is 
now floated upon the contents of the tube. It is most easily deposited 
there with the aid of a pipette. (Fig. 190.) One c.c. of urine is then 
floated upon the water, taking care that the liquids do not mix. The 
open end of the tube is now quickly closed securelv 
by pressing the thumb firmly upon it. The con- 
tents are mixed by gently shaking. When the 
effervescence has ceased, the reading is taken at the 
top of the liquid column, while the tube is held 
inverted. The end of the tube, still closed by the 
thumb, is now submerged in a large jar of water. 
The thumb is then removed, and the tube raised 
or lowered, till the surface of the liquid in the 
tube is at the same level with that in the jar, and 
the reading is again taken. The difference be- 
tween the two readings indicates the number of 
grains of urea in a fluidounce of the urine. This 
number multiplied by the number of fluidounces 
of urine voided in twenty-four hours gives in 
grains the total quantity of urea excreted during 
the day. The average daily amount is about 500 
grains, but is liable to considerable variation 
within normal limits. The subject will be treated 
more fully under eclampsia. 

The Nipples. Inquiry should be made with refer- 
ence to the condition of the nipples. If they are 
small, depressed, or misshapen the patient should 
be directed to draw them out daily with the thumb 
and fingers. The manipulation not only helps to 
develop the nipples, but it renders them less liable to injury by the 
child's mouth in nursing. 

Inversion and other deformities of the nipples are often the result of 
pressure from tight clothing; for this the remedy is obvious. 

The sebaceous secretion which accumulates upon the nipples affords a 
nidus for the growth of micro-organisms, and uncleanliness is doubtless 
a prominent factor in infection of the nipples and resulting mastitis 
during lactation. Special attention should be paid to the cleanliness of 
these parts during the later months of pregnancy. A borax solution, one 
tablespoonful to the pint of water, is a good detergent. Bathing with 
this once daily is useful as a prophylactic against the occurrence of sore 
nipples during the nursing period. 

The following method has been recommended for the prevention of 
fissured nipples during lactation ; every night in the last two month- 



Graduated tube. Pipette. 
(Bartley.) 



THE MANAGEMENT OF NORMAL LABOR. 213 

of pregnancy the patient anoints the nipples with lanolin, kneading 
them with the thumb and fingers. The hands must first have been 
cleansed carefully with soap and hot water. In the morning the nipples 
are cleansed by prolonged brushing with a soft brash and pure soap 
and water. 

ANTEPARTAL EXAMINATION. 

It is the duty of the obstetrician to inform himself before labor of 
the presentation and position of the child, the relative size of head and 
pelvis, and, as far as possible, of all the obstetric facts which may bear 
upon the result of the labor. This is usually done at about the end of 
the eighth month. The antepartum examination is conducted accord- 
ing to the following scheme : 

A. Abdominal Examination. 

Diagnosis of Presentation and Position of Fcetus. 

Preparation. The patient lies in the horizontal position on a hard bed or 
table, the examiner standing or sitting at either side. The bladder and 
the rectum must be empty. The abdomen may be fully exposed or be 
covered with a thin sheet. If the sheet is used the examination is con- 
ducted through it or with the hands on the abdomen beneath it. The 
examiner first bathes his hands in warm water. This renders the tactile 
sense more acute and tends to prevent reflex contractions of the abdom- 
inal and uterine muscles which would be excited by contact of cold 
hands. 

Location of Child's Back and the Small Parts. Three methods are avail- 
able. One or all may be employed. 

1. The child's back and the limbs or small parts usually may be made 
out by palpating systematically the entire surface of the abdominal tumor. 
Only the volar surfaces of the finger-tips are applied, and the touch 
should be light. The tactile sense is keenest with but moderate pressure. 
Deeper pressure is only occasionally necessary to make out the degree 
of resistance, the hardness, and the mobility of the foetal parts beneath 
the fingers. 

The small parts are felt as small nodules, knees, ankles, elbows, etc., 
which glide about freely under the touch. They are identified by cir- 
cling motions of the fingers with moderate pressure. Sometimes a foetal 
extremity may be mapped out through the greater part of its length. 

2. The foetal dorsum is more readily palpated if the trunk is steadied 
by pressure in line with the long axis of the foetus, the hand being held 
over the upper foetal pole. This increases the convexity of the dorsal 
plane and brings it nearer to the examining hand. 

3. Applying one hand flat on the middle section of the abdomen, mod- 
erately deep pressure displaces the foetus to the side toward which its 
back lies and the liquor amnii to the opposite side. Still maintaining the 
pressure, the hard body of the foetus may be felt on one side of the abdo- 
men and only fluid on the other side. (Fig. 191.) 

By these simple manipulations it is usually possible to determine to 
which side of the mother the child's back lies. 



214 



PHYSIOLOGY OF LABOR. 



To learn whether the back of the child is turned toward the back or 
front of the mother it will be necessary to distinguish the dorsal from 
the lateral plane of the foetus. The back offers a broad resisting surface 
w T hich is somewhat convex from end to end, and which runs off smoothly 
upon the head. The lateral plane of the foetus is narrower; it is not 
convex from end to end, and a sulcus is felt between it and the head. 

Except in twins, where legs and arms can usually be felt in various 
directions, finding the small parts in one section of the abdomen confirms 
the location of the dorsum in the opposite region. Small parts to the 
right indicate a left, small parts to the left indicate a right position of 
the foetus. Small parts few and hard to find suggest an anterior position 



Fig. 191. 




Displacing foetus to one side of abdomen for locating dorsal plane. 



of the child; small parts numerous and found near the middle section of 
the abdomen usually point to a dorso-posterior position of the foetus. 
If small parts can be felt beyond either end of the foetal ellipsoid, that 
end is pretty surely the breech. 

The examination, thus far, as a rule, presents little difficulty. When 
the abdominal wall is over- fat or rigid, the uterus contracted, or tense 
from distention, as in hydramnios and certain other conditions, the foetal 
parts are often more or less obscured. 

Palpation of the Lower Foetal Pole. The hands are placed over the 
lateral aspects of the lower abdomen with their palmar surfaces nearly 



THE MANAGEMENT OF NORMAL LABOR. 



215 



facing each other, the finger-tips toward the mother's feet. The ends of 
the fingers should rest at first a little above Poupart's ligament. The 
hands are pressed downward toward the excavation, and backward 
toward the mother's back, till the lower foetal pole is caught between 
them. (Fig. 192.) If not readily found the object may sometimes be 
gained by moving the hands sharply from side to side, as if to toss the 
foetal pole from one hand to the other, the hands meantime being brought 
nearer and nearer together. 

The first object now is to find whether the foetal pole under examina- 
tion is the head or the breech. The two poles are distinguished by the 
following characteristics: The head is hard and globular, and it presents 



Fig. 192. 




Palpation of lower foetal pole. 



a sulcus laterally between itself and the trunk. Again, the head is the 
only foetal part that sinks into the pelvic excavation before labor. In 
primigravidse, as a rule, the head when it presents is found in the lesser 
pelvis during the last one or two months of pregnancy; in multigravidse, 
owing to greater laxity of the abdominal walls, it lies above it till the 
period of lightening, and in two-thirds of the cases till labor begins. 
When, therefore, the presenting pole of the foetus is found in the excava- 
tion before labor, that pole is the head. The breech is alone smaller, 
with the extremities larger, than the head. It lacks the hardness and the 



216 



PHYSIOLOGY OF LABOR. 



globular shape of the head ; it presents no sulcus, and in all cases it lies 
above the excavation till labor is established. 

The presence of the lower foetal pole in one iliac fossa means a trans- 
verse presentation. 

Palpation of the Upper Fcetal Pole. The hands are placed on the abdo- 
men over the upper portion of the uterus with the finger-tips toward the 
mother's head, the volar surfaces of the hands nearly facing each other. 
(Fig. 193.) The upper foetal pole is now palpated for the distinguishing 
marks of the head or the breech. The poles are distinguished by the 
characters already given and by the fact that the head when in the upper 
uterine segment is susceptible of ballottement. The head can be tossed 
from side to side between the hands, or be made to bob under the fingers 



Fig. 193. 




Palpation of upper foetal pole. 



light 



intermittent thrusts through the abdominal wall with one 



by 

hand. 

The breech lacks the flexible attachment to the trunk which marks the 
head, and it has little mobility not only because of this, but also by 
reason of the greater bulk of the component elements of the pelvic end 
of the foetal ovoid. 

Location of the Anterior Shoulder. The hands are held firmly upon the 
abdomen over the sides of the foetal head and without relaxing the press- 
ure moved toward the trunk. The first obstacle encountered is the 
anterior shoulder. It is more surely identified by palpating it with one 
hand while the other steadies the foetus by downward pressure upon 



THE MANAGEMENT OF NORMAL LABOR. 



217 



the breech in the direction of the foetal axis. (Fig. 194.) It presents 
a small rounded prominence immovably attached to the trunk. Some- 
times its anatomical elements can be traced. 

Finding the anterior shoulder on the left of the median line of the 
abdomen in vertex presentation indicates a left, on the right a right posi- 
tion of the foetus. Anterior shoulder within one or two inches of the 
median line indicates an anterior, several inches from the median line a 
posterior foetal position. 

Location of the Cephalic Prominence. When the head lies in the exca- 
vation in vertex presentation the occipital pole, owing to head flexion, 
sinks more deeply in the cavity than the sinciput. The latter lies at or 
just above the brim; therefore, the greatest cephalic prominence at the 

Fig. 194. 




Locating anterior shoulder. 



brim corresponds to the sinciput. It is located by laying the hand 
across the lower abdomen just above the symphysis and grasping the 
head (Figs. 195 and 196). The situation of the greater prominence 
may also be made out by palpation with both hands, as shown in Fig, 
197. The hand on the side on which the occiput lies sinks more deeply 
into the excavation than the other. The prominence of the sinciput is 
naturally most marked in ocoipito-posterior positions. 



218 



PHYSIOLOGY OF LABOR. 



Location of the Foetal Heart. Auscultation may be practised with or 
without the stethoscope. The room must be still. For immediate aus- 
cultation, without the stethoscope, the abdomen is covered with a thin sheet 
or towel. Since a continuous solid medium helps conduction, the abdom- 
inal wall should be pressed firmly against the uterus. Downward press- 
ure of the breech in the direction of the long axis of the foetus facilitates 
the examination by thrusting the dorsum forward. The focus of auscul- 
tation, the point at which the heart-tones can be heard loudest, as a rule, 
nearly overlies the lower angle of the left foetal scapula. 

Foetal heart on the left of the median line indicates a left, on the 
right, a right position of the foetus. Foetal heart near the median line 
points to an anterior, far away from it, to a posterior foetal position. 
When the foetal heart is above the umbilicus the presentation is generally 
a breech, when below it, a vertex presentation. The location of the 



Fig. 195. 




Locating cephalic p 



>minence by grasping foetal head with hand held across 
the suprapubic region. 



heart-tones, however, cannot be wholly relied on for the diagnosis of 
presentation. The heart lies nearly midway between the two extremities 
of the foetal ellipsoid. Its height in the abdomen is, therefore, not mate- 
rially affected by the presentation in multigravidse in whom neither foetal 
pole sinks into the excavation before labor. In primigravida?, in whom 
the foetus rests lower in vertex than in breech presentation, the location 
of the foetal heart is of some value for the diagnosis of presentation. 
Sometimes it happens that the focus of auscultation does not immedi- 



THE MANAGEMENT OF NORMAL LABOR. 219 

ately overlie the heart. It may be found at some remote point in con- 

Fig. 196. 




Diagram showing relation of hand to foetal head in manipulation for locating 
cephalic prominence. 

sequence of firmer contact of the foetus with the uterine wall at that 
point. For a like reason a second focus may in rare instances be found. 



Fig. 197. 




Diagram showing method of locating cephalic prominence by palpation with 
both hands. 

In dorso-posterior positions, in hydramnios, and in certain other con- 
ditions the heart-sounds are not always audible. 

Conclusions. A complete abdominal examination usually affords more 



220 PHYSIOLOGY OF LABOR. 

reliable data for determining the foetal presentation and position than 
does the internal examination. With rare exceptions a definite and posi- 
tive diagnosis is easily reached. The examiner should accustom him- 
self to reserve his decision till the facts are all in hand, basing his 
conclusion upon the sum total of the findings. 

Abnormal Conditions. 

In course of the abdominal examination pathological conditions of 
maternal or foetal origin that may complicate the labor are to be looked 
for. Morbid growths in the abdomen or pelvis may be detected by 
palpation. The presence of hydramnios or of pendulous abdomen is 
noted. Excessive size and persistent tension of the uterine tumor should 
suggest twins. A definite diagnosis is usually possible. Hydrocephalus 
ought to be recognized by palpation. It is more surely made out by 
measurements taken through the abdominal wall with calipers. 

The location of the placenta when implanted anteriorly can sometimes be 
determined in the external examination. The convex margin can occasion- 
ally be felt as a resisting ring; within the placental area the foetal parts are 
obscure to the touch, w r hile elsewhere they are easily detected. Thus the 
diagnosis of placenta praevia is sometimes possible by external palpation. 

External Pelvimetry. 

In connection with the abdominal examination external measurements 
of the pelvis are to be taken, except in cases in which there is ample 

Fig. 198. 




Collyer's pelvimeter. 



assurance from the character of previous labors that the pelvis is normal. 
Extreme contraction or marked asymmetry is readily recognized by 



THE MANAGEMENT OF NORMAL LABOR. 



221 



palpation. Slight deformities are detected only by systematic measure- 
ment. For this purpose a suitable pelvimeter will be required. (Fig. 
198.) Most essential are the antero-posterior diameter of the pelvis or 



Fig. 199. 




Measuring the external conjugate. The dimples corresponding to the posterior 
superior spines of the ilium are shown in the figure. 

the external conjugate, the interspinal, the intercristal, and the external 
oblique diameters. Of these the diameter of greatest practical value is 
the external conjugate. 

The external conjugate is measured from the fossa just below the spine 
of the last lumbar vertebra to a point on the pubic surface just below 

Fig. 200. 




Measuring the intercristal diameter. 



the top of the symphysis. (Fig. 199.) To locate the last lumbar spine 
draw an imaginary line between the dimples corresponding to the pos- 
terior superior iliac spines. The second vertebral spine above this line is 
the last lumbar. The external conjugate diameter, or, as it is sometimes 
called, the diameter of Baudelocque, is nearly parallel with the plane of 
the brim and with the internal conjugate. 



222 PHYSIOLOGY OF LABOR. 

The method of measuring the intercristal diameter (Fig. 200) and the 
interspinal diameter is obvious. (See p. 170.) 

The external measurements are fairly reliable as evidence of the shape 
and capacity of the pelvis internally. When all are small the pelvis is 
generally contracted. If the interspinal is equal to or greater than the 
intercristal diameter the pelvis is flattened. Inequality in the external 
oblique diameters is evidence of asymmetry. 

To find the true conjugate from the diameter of Baudelocque, from 7 
to 12.5 cm ., 2} to 5 inches, must be deducted from the latter, according 
to the estimated thickness of the bones and the soft parts, the inclina- 
tion of the symphysis, and the height of the sacral promontory. 

Since it is impossible to know the exact allowance to be made in a 
given case, the external conjugate cannot be wholly relied on for detect- 
ing pelvic contraction. Yet it may safely be assumed that the pelvis is 
flattened when the diameter of Baudelocque falls below 16 cm., 6^ 
inches, or that it is ample when the external conjugate exceeds 21 cm., 
8 J inches. As a general rule, contraction should be suspected when the 
external conjugate is less than 18 cm., 7 inches; the true conjugate is 
probably, though by no means surely, ample when the external conjugate 
is above 18 cm. 

B. Vaginal Examination. 

An internal exploration is advisable in all cases as a part of the pre- 
liminary examination; in women pregnant for the first time and in others 
whose obstetric history leads to suspicion of pelvic deformity, it is im- 
perative. The objects are to learn the condition of the soft parts — vulva, 
vagina, cervix, especially in multigravidse — to confirm the diagnosis of 
presentation, to detect a possible vicious insertion of the placenta, and to 
determine the capacity of the bony pelvis. 

Antiseptic Preparation. The external genitals of the patient and the 
hands of the examiner should be prepared with the same care as for 
internal examinations during labor. For the technique of disinfection 
the reader is referred to page 228. 

Examination of the Soft Parts. In multigravidse the vulva, the vagina, 
and the cervix are first examined for injuries resulting from previous 
deliveries. In all cases it should be noted whether pathological growths 
or congenital defects of the soft parts, which may complicate the labor, are 
present. A cephalic presentation, as a rule, may readily be made out, 
even before dilatation of the cervix, by the touch through the uterine 
wall. A low implantation of the placenta in advance of the head 
should readily be detected. 

Internal Pelvimetry. Most important is the examination of the bony 
pelvis. This should include the pelvic inclination, the configuration of 
the pelvis, the depth and inclination of the symphysis pubis, the shape 
of the sacrum, the height of the promontory, and the relative size of 
the head and pelvis. The pelvic diameters, especially at the inlet and 
the outlet, should be definitely determined. 

For internal pelvimetry the hand, as a rule, is the best instrument. 
The shape of the sacrum and the general capacity of the pelvis can be 
estimated approximately by palpation. 



THE MANAGEMENT OF NORMAL LABOR. 



223 



The Pubococcygeal Diameter is measured by placing the end of 
the second finger against the tip of the coccyx and bringing the radial 
edge of the outstretched hand in contact with the subpubic ligament. 
The point at which the latter rests against the hand is then marked by 
a finger of the other hand. On withdrawing the hand the distance be- 
tween the tw r o points of contact is measured with tape or calipers. 

The Sacropubic Diameter is measured in like manner. 

The Transverse Diameter at the outlet is best measured externally. 
With the patient in the lithotomy position the examiner places the 
thumbs upon the skin over the ischial tuberosities. The palmar surfaces 
of the thumbs are pressed firmly against the inner aspects of the tuber- 
osities at the level of a line running through the anterior margin of the 
anus. The distance between the two points of contact is then measured 
by an assistant. Under an anaesthetic during labor this diameter may 
be estimated also by introducing the extended hand partly within the 
vaginal orifice between the tuberosities, and comparing the bisischial 
space with the width of the hand near the finger-tips. 

The Diagonal Conjugate is measured as follows: With the patient 
in the lithotomy position tw r o fingers of one hand are passed into the 
vagina. If the head is found resting deeply in the lesser pelvis in the 
ninth month of pregnancy the relative capacity of the brim is assured 
and the measurement is unnecessary. Should only the occipital pole 
have sunk into the excavation it may be pushed up. The finger-tips are 
carried up and down over the region of the sacral promontory till the 
most prominent point is found. Against this the ulnar margin of the 
second finger-tip is held firmly. The radial edge of the hand is then 
raised till it rests against the subpubic ligament. The latter point of 
contact is marked by a finger-nail of the other hand. (Fig. 201.) On 



Fig. 201. 




Manual method of measuring the diagonal conjugate. 



withdrawing the hand the distance between the two points of contact 
is measured as in the case of the pubo-coccygeal diameter. 

The True Conjugate is computed from the diagonal, since the former 



224 



PHYSIOLOGY OF LAB OB. 



cannot be measured directly. The diagonal conjugate corresponds nearly 
to the hypothenuse of a triangle of which the base is the true conjugate. 
Generally the latter is obtained by subtracting from a half to three- 
fourths of an inch from the diagonal conjugate. The amount to be 
deducted, however, will vary with the depth and the thickness of the 



Fig. 202. 




Hirst's pelvimeter adjusted for measuring from promontory to front of symphysis. 



symphysis pubis, with its inclination, and with the height of the sacral 
promontory. 

As these elements in the question are variable and their value in the 
individual case cannot be determined with accuracy, the estimation of 
the true conjugate by the foregoing plan is only approximate. A possi- 



FlG. 203. 




Pelvimeter adjusted for measuring thickness of symphysis. 

ble error of at least a quarter of an inch must be assumed in all cases ; 
frequently it is greater. 

For more exact determination of the true conjugate Hirst, with an 
instrument of his own device, measures the distance from the promon- 
tory to the anterior aspect of the symphysis two-fifths of an inch below 
its upper margin. The thickness of the pubic joint is then measured 
with the same instrument, and the difference between the two measures 
gives the precise value of the true conjugate. 



CASE RECORDS. 

The habit of keeping systematic records conduces to thoroughness in 
the management of cases. It would be well if physicians in private 
practice, as in hospital work, made use of blanks for obstetric histories. 

The following is a simple form for obstetric records which may be 
modified to suit the requirements of individual practitioners: 



THE MANAGEMENT OF NORMAL LABOR. 225 



Obstetric Record. 
Case of Application No. 

Date of application 19 

HISTORY. 

Residence Nationality Married Single Widow 

para Character of previous labors Puerperiums 
Miscarriages 

Last menses, date duration quantity 



Quickening, date 



ANTE-PARTUM EXAMINATION. 

Date 19 



General health 

Heart 

Lungs 

f Amount 



Reaction 

Specific gravity f Size 

Albumin j Veins 

Urine -j Sugar Breasts \ Areolae 

Total solids j Nipples 

Urea [_ Papillae 

Casts 
[ Other microscopic findings 



ABDOMINAL EXAMINATION. 

Dorsum of foetus, to mother's front back, right left 

Foetal head, where found size Foetal movements 

f Rate 
Anterior shoulder, where found Foetal heart -j ^ J^nm 

I Location 
Height of fundus above symphysis 
Liquor amnii, scanty normal excessive 
Foetus, one two Length of foetal ovoid 

External conjugate Interspinal diameter Intercristal diameter Obliques 

Location of placenta Complicating tumors 

VAGINAL EXAMINATION. 

Condition of vulva, old injuries oedema rigidity 

f Mucous membrane, healthy or not «. 

Vagina -{ Secretion, healthy or not Cervix ] ^f? . 

I Other abnormalities /m j • • ^ 

L (_ Old injuries 

Diagonal conjugate True conjugate Other diameters 

LABOR. 

Date 189 

Stage of Dilatation. Pains began frequency character 

General condition of patient Temperature Pulse 

Bladder, full or empty Rectum, full or empty Membranes ruptured or not 

Presentation Position Posture 

f Rate 

Foetal heart \ ^^ 
j t orce 

[ Location 

Number of vaginal examinations 

Complications and medication Duration 

15 



226 



Stage of Expulsion, 
f Kate 

F«U1 heart \ ™£»» 

I Location 
Membranes ruptured, when 
Perineal stage, duration 
Number of vaginal examinations 
Complications, medication, operations 



PHYSIOLOGY OF LABOR, 

Pulse Temperature Character of pains 

Vaginal secretion, free or scanty 



how 
management 



Duration 

Placental Stage. 

Placenta, delivered at 

size shape 

Membranes, complete or not 
Umbilical cord, insertion 
Uterus, degrees of retraction 
Injuries 
General condition of patient 

Child, male female, alive dead, length 



method 




seat 


anomalies 


how removed 




length 


anomalies 


eight of fundus 


shape 


Medication 




Pulse 


Temperature 


length 


weight 



Head 



Diameters 



OM 



OF 



SOB 



BIP 



\ Circumferences 
Inj uries 

Congenital anomalies 
Temperature in rectum shortly after birth 



BIT 



Rectum and urethra, pervious or not 























TEMPERATURE ANC 


PI 


JLS 


E 




















Day 
Date 


1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


11 


12 


13 


14 


Temp. 






























C. F. 
41.1° 106° 

40.6 105 
40.0 104 
39.4 103 
38.9 102 
38.3 101 

37.7 100 
37.2 99 
36.7 98 














































































































































































































































































































































































































































































































































































Pulse 
180 
170 
160 
150 
140 
130 
120 
110 
100 
90 
80 
70 
60 
50 
40 









































































































































































































































































































































































































































































































































































































































































































































































































































































THE MANAGEMENT OF NORMAL LABOR. 227 



MOTHER. 


CHILD. 


Diet Breasts 
Bowels Bladder 
Uterus Lochia 
Treatment 


General condition Tempers 
Eyes 

r Mouth 
Digestive organs < Stomach 

( Bowels 
Bladder Umbilical wound 
Weekly gain in weight 



CONDITION ON DISMISSAL. 

Date 19 

General condition of mother 

Uterus, size position shape 

Cervix, size shape position injuries 

Vulva and vagina, injuries 
Child 



Obstetric Armamentarium. Such instruments and drugs as are likely 
to be needed in the conduct of ordinary labor and in the more important 
emergencies of the lying-in room should be carried in the obstetric bag. 
The usual outfit comprises : a pelvimeter, an obstetric forceps, a hypo- 
dermic syringe, a gravity or a Davidson syringe, a glass douche tube, a 
soft rubber catheter, a soft-rubber tube with bulb attached for clearing the 
child's pharynx in case of partial asphyxia, a hollow needle for hypo- 
dermoclysis, a Sims speculum, a double tenaculum, a straight uterine 
dressing forceps, a curette about 14 inches in length, needle forceps ; 
needles moderately curved and of assorted sizes from 4 to 7 cm., or 1 \ 
to 2^ inches, in length, for suturing lacerations ; scissors, aseptic sutures 
of catgut and of silk and of silkworm-gut in hermetically sealed bottles 
or glass tubes, a straight, blunt-pointed bistoury for episiotomy, two 
hand-brushes, a set of dilating water-bags, and a sealed package of 2 
per cent, sterilized gauze, enough to fill the post-partum uterus. 

The drugs most frequently needed are : chloroform, ether, ergot, digi- 
talis, veratrum viride, trinitrin, morphine, chloral, and mercuric chlo- 
ride or iodide. All except the anaesthetics may be had in tablet form. 

A useful apparatus in forceps delivery in the absence of competent 
assistance is Buckmaster's or Robb's leg-holder for holding the thighs 
flexed on the abdomen. It is about three inches wide and two yards 
long, and is made of duck. At one end is a loop, which is slipped over 
one leg just below the knee. The band is carried over one shoulder, 
across the back, under the other shoulder, and fastened below the other 
knee. The band is so adjusted that it pulls from the outer side of the 
leg loop, abducting the knees. If made of thin material, the apparatus 
occupies but little room in the obstetric bag. 

Obstetric Antisepsis. 

To an obstetrician, Ignatius P. Semmelweis, belongs the credit of first 
putting into practice the principles of the present antiseptic system. In 
1847, while an assistant in the Lying-in Department of the Vienna Gen- 
eral Hospital, he was deeply impressed by the high mortality that pre- 



228 PHYSIOLOGY OF LABOR. 

vailed in the service. This mortality he soon found was greatest in the 
students' clinic. Nearly 10 per cent, of the women delivered in that 
branch of the service died. The students were engaged in the work of 
the dissecting-room and the dead-house at the same time that they were 
pursuing the course in practical obstetrics. In the midwives' clinic, on 
the other hand, the mortality seldom exceeded 3 per cent. Prolonged 
labor in the students' clinic was almost uniformly followed by death; 
while in the midwives' clinic the length of the labor made little differ- 
ence in the death-rate. Semmelweis had also observed that women 
delivered before admission and unattended wholly escaped the fatal 
fever. While pursuing these observations one of his associates, Professor 
Kolletschka, died from a dissection wound. The similarity of his col- 
league's symptoms to those presented by the puerperal women dying of 
fever was apparent. It immediately dawned upon Semmelweis that the 
cause of the fatal malady in the lying-in service was the same as that 
which had resulted in the death of his colleague. Acting on this belief, 
he required the students to wash their hands in chlorine water before 
making internal examinations, and he restricted the number of such 
examinations. The death-rate immediately fell, and in little more than 
a year it had been reduced to less than 2 per cent. Thus was established, 
the first step toward one of the most important' of modern surgical dis- 
coveries. 

Antiseptic Agents. 

Mechanical Cleansing. Not the least important part of the antiseptic 
technique is the mechanical cleansing. This removes the greater part of 
the offending material. A well-polished instrument may be rendered 
almost sterile to culture tests by prolonged brushing with soap and hot 
water, and finally washing well with sterilized water. For the operation- 
field and for the hands and arms of the operator this part of the process 
is doubly necessary, since the removal of surface epithelium and seba- 
ceous matter not only carries with it the major portion of the infectious 
material, but it is essential to the action of the chemical antiseptics. 
Freed from fatty matter and well wet by the soap-and- water scrubbing, 
the skin readily absorbs the antiseptic solution. 

Heat is at once the most generally available and the most reliable 
germicide; either dry or moist heat may be used. Moist heat is much 
the more effective. 

Dry Heat. Exposure for three hours to a temperature of 140° C. 
(284° F.) kills all pathogenic organisms and their spores. A special 
apparatus may be employed or the oven of a cooking-range can be util- 
ized. A thermometer capable of registering 148° C. (300° F.) or more 
must be used for regulating the temperature. Dressings, however, are 
penetrated by hot air only very slowly, and the method is, therefore, 
inadvisable for such material. It may serve for such utensils as are 
capable of withstanding prolonged baking without injury, but the 
length of time required renders it unsuitable for general use. 

Moist Heat is employed in the form of steam and of boiling water. 

Steam is effectual at a temperature of 100° C. (212° F.j when in 
motion. Superheated steam partakes of the disadvantages of hot air, 
and moist steam acts to the best advantage only as flowing steam. Expos- 



THE MANAGEMENT OF NORMAL LABOR. 229 

lire for thirty minutes to flowing steam at 100° C. is almost absolutely 
reliable. In institutions steam sterilizing is now generally practised under 
a pressure of fifteen pounds, temperature 121° C., 250° F., or more, by 
means of an autoclave. Special provision is made to secure penetration. 
Numerous forms of steam sterilizers are to be had. A cheap and con- 
venient apparatus for the purpose is the Arnold steam sterilizer, or one 
of its modifications. 

Boiling for five minutes in water kills all pathogenic organisms likely 
to be encountered and their spores. One of the most effective of all 
practicable methods of using heat is boiling for five or ten minutes in a 
1 per cent, solution of sodium carbonate or bicarbonate. Articles so 
treated are sterilized in less time than in boiling water. Even the most 
resistant spores are destroyed in less than five minutes. The addition 
of the soda has the further advantage that it protects metallic instru- 
ments from tarnishing, and it removes fatty matter. For instruments 
it is desirable that the soda be chemically pure, since the impurities in 
the commercial article may cause corrosion. A fish-boiler or a wash- 
boiler may be utilized in the absence of a special sterilizing apparatus. 
Boiling in the soda solution is the method now generally employed for 
sterilizing instruments. For convenience in handling, instruments are 
best deposited in a wire basket or in a folded towel during the boiling. 
Steam sterilizing is especially applicable for dressings and utensils. 

Chemical Antisepsis. Among the most useful chemical germicides may 
be mentioned the mercuric chloride or iodide and carbolic acid. Creolin, 
lysol, and a multitude of other antiseptics more or less extensively used 
by obstetricians offer little or no special advantage. Chlorinated soda 
solution, peroxide of hydrogen, 3 per cent, solution, and iodine water 
have the merit of being non- toxic. 

Mercuric chloride is decomposed in the presence of alkalies or of albu- 
min. In contact with the former the mercury is precipitated in the form 
of an oxide, and ia the presence of the latter an albuminate of mercury 
is formed. A plain sublimate solution, therefore, soon becomes inert if 
mixed with bloody fluids. To prevent these changes, solutions of the 
bichloride of mercury for antiseptic use are acidulated with five parts 
of tartaric, acetic, or hydrochloric acid to one of the mercurial. The 
biniodide of mercury, on the other hand, yields a precipitate with albumin 
in acid, but not in neutral or alkaline solutions. The addition, however, 
of an equal weight of potassic iodide is required to render it freely solu- 
ble. These two mercuric salts are equally active as germicides, or nearly 
so, in solutions of equal strength. The strengths most commonly em- 
ployed are from 1 : 5000 to 1 : 500. 

The following formulas represent some of the autiseptic solutions used 
in obstetric practice: 

Mercuric Chloride (Sublimate) Solution, 1 : 2000. 

Bichloride of mercury Gr. yijss. 

Tartaric acid Gr. xl. 

Sterilized water Oij. 

Mercuric Iodide Solution, 1 : 2000. 

Biniodide of mercury ) . . 

Potassic iodide ■/ aa . . , Gr. vijss. 

Sterilized water Oij. 



230 PHYSIOLOGY OF LABOR. 

Chlorinated Soda Solution, 1 : 10. 

Labarraque's solution Sj. 

Sterilized water Six. 

Creolin Solution, 1 : 100. 

Creolin Sijss. 

Sterilized water Oij. 

Carbolic Solution, 1 : 20. 

Carbolic acid 5J24. 

Glycerin . Siij. 

Sterilized water Oij. 

Convenience and accuracy in the employment of the mercurial anti- 
septics are promoted by the use of tablets containing the required chemi- 
cal ingredients. 

The peroxide of hydrogen solution may be used plain or diluted with 
two to four volumes of sterilized water; iodine-water 2 per cent, 
strength. The latter may be prepared by diluting tincture of iodine 
with water till it is of a port-wine color, adding enough potassic iodide 
to hold the iodine in solution. 

Choice of Methods. 

Since sterilization by exposure to the action of chemical solutions is 
uncertain and often imperfect, the latter should be reserved for pur- 
poses to which heat is not applicable. Their employment is limited 
almost wholly to skin disinfection. 

Boiling, steaming, or even hot air may be used for utensils, or dress- 
ings which are not likely to be injured thereby. 

At or just before the onset of labor the nurse should sterilize by steam 
a supply of towels, cheesecloths for sponging, the vulvar dressings, and 
the ligature for the umbilical cord. They are first enveloped in a towel 
which is pinned securely, and in this they are kept after sterilizing till 
they are wanted for use. 

Obstetric forceps, needle forceps, needles, scissors, and such other 
instruments as may be required, are wrapped in like manner and boiled 
for five minutes in water or, better, in the soda solution. 

The Obstetrician. 

Of first importance is the asepsis of the hands. A hand-brush, soft 
soap, and a supply of the required chemical antiseptics are essential parts 
of the obstetrician's armamentarium. Soft soap may conveniently be 
carried in collapsible metal tubes. The chemical agents are carried in 
tablets or in the form of powders. The soap may be sterilized by heat- 
ing to 100° C, and the hand-brushes by boiling in the soda solution. 
It is desirable that the hand-basin used for the soap and water cleansing, 
and those containing antiseptic solutions, be sterile. 

Cleansing the Hands. 

The hands and forearms are prepared by one of the following methods 
before contact with the genitals of the lying-in patient: 



THE MANAGEMENT OF NORMAL LABOR. 231 



Furbringer Method— Modified. 

(a) They are brushed systematically for ten minutes with soap and 
hot water and a hand-brush. The water is used as hot as can be borne. 
Special attention must be given to the finger-tips, the sides of the fingers, 
and the subungual spaces. 

(6) The nails are then cleaned with a nail-cleaner and again brushed 
for five minutes. The instrument should not be sharp, but should 
rather have moderately blunt edges, which may leave the surface of the 
nails smooth and polished. A piece of soft wood sharpened to a blunt 
point is a good substitute for the usual toilet article. It is made aseptic 
by boiling or steaming before using. The nails should constantly be 
kept short with their cut edges smoothed and polished, and the corners 
rounded. 

After the soap-and-water cleansing the soap is removed by rinsing 
the hands in sterile water. 

(c) Finally, the hands and forearms are immersed for five minutes in 
a 1 : 2000 mercuric chloride solution. 

It is a distinct gain to saturate the skin for a minute with alcohol 
before immersion in the antiseptic solution. The alcohol should be of 
about 75 per cent, strength. This acts in some degree as a solvent 
for sebaceous material that may have escaped the soap-and-water cleans- 
ing, and it dehydrates the outer layer of the skin, thus permitting the 
antiseptic to sink more deeply. 

Permanganate Method. 

Steps (a) and (b) are carried out as in the preceding method. 

(c) The hands and forearms are then immersed for five minutes in a 
saturated solution of potassium permanganate in hot boiled water till of 
a deep mahogany-brown color. 

(d) The hands and forearms are now held in a saturated solution of 
oxalic acid in sterile hot water till the brown stain is completely dis- 
charged. 

(<?) Lastly, they are immersed for three minutes in a 1 : 500 mer- 
curial solution. 

Chlorinated Soda Method. 

Steps (a) and (b) are the same as before. 

(c) The hands and forearms are then covered with a paste made by 
wetting chlorinated lime with water. They are next rubbed with a 
lump of crystallized sodic carbonate (washing-soda) till a sensation of 
cold is felt. This yields chlorinated soda in its nascent state, which is 
the active disinfectant. Friction is now applied with a hand-brush for 
five minutes. 

(d) The chemical is w r ashed off with sterilized water and the skin 
surface is rinsed with alcohol or with weak ammonia water. 

(e) By the permanganate or the chlorinated soda process the hands 
usually may be rendered practically sterile. Yet absolute disinfection 
is impossible, especially after infection by virulent exposures. 



232 PHYSIOLOGY OF LABOR. 

Precautions. 

After cleansing the hands care must constantly be observed to pre- 
vent reinfecting them. Contact of the hands with any object that is 
not aseptic must be scrupulously avoided. Frequent rinsing with the 
antiseptic solution is essential during attendance on the labor, since 
germs are constantly coming to the surface from the sweat-glands and 
hair-follicles where they had escaped the primary disinfection. Keep- 
ing the hands wet with glycerin containing a grain to the ounce of one 
of the usual mercurial salts favors continuous disinfection and helps to 
keep the skin soft. The glycerin should have been sterilized by heat. 

Operating Suit. During actual attendance on the patient the obstetri- 
cian wears a freshly sterilized operating gown, or he may prefer a coat 
and trousers of white duck or linen, to be worn over his usual clothing. 

Lubricants. For digital examinations within the passages no lubri- 
cant is required, as a rule. It is generally sufficient that the fingers be 
wet with the antiseptic solution. Should any other lubrication be 
required, as, for example, when the hand is to be introduced within the 
vagina, the back of the hand may be smeared with glycerin or with 
vaseline which has been heated for ten minutes to 100° C. 

Boiled Gloves. Should the physician be called upon to attend a labor 
directly after septic contact or when scant time is allowed for rigorous 
disinfection, he may wear rubber gloves which have been sterilized by 
boiling in water or in a solution of common salt. The soda solution is 
unsuitable, since it rapidly destroys the rubber. Lacking these, such 
manipulations as are required during the perineal .stage of natural labor 
may safely be conducted through the intervention of an aseptic towel. 
In a considerable proportion of cases it is possible to manage the labor, if 
need be, without direct contact of the hands with the field of the 
obstetric wounds. The experiences of Kelly and of Zweifel have shown 
that no method of skin sterilizing can fully be trusted directly after 
exposure to an acute infectious process. 

There is no kind of surgical work in which the routine use of rubber 
gloves finds a more appropriate application than in obstetrics. It is the 
writer's practice to wear them in practically all cases during attendance 
on labors. Since the gloves may be punctured or torn in use, the disin- 
fection of the hands should be carried out as carefully as when gloves 
are not to be worn. 

The Nurse. 

It is scarcely necessary to say that the nurse must be no less careful 
in all particulars than the doctor is required to be in the observance 
of antiseptic details. Her clothing must be scrupulously clean, and 
she should wear wash-dresses. As an extra precaution she must 
refrain from attendance on obstetric patients for a week or more after 
a septic exposure. During that time her hands and forearms are to 
be sterilized repeatedly, and she should take two or three full baths, 
with special pains to cleanse the hair. In all cases the nurse makes 
an entire change of clothing on taking charge of a patient in labor. 

The Patient. 

The aseptic preparation of the obstetric patient ought to begin weeks 
before the labor. She is to be taught the importance of daily bathing 



THE MANAGEMENT OF NORMAL LABOR. 233 

and of strict cleanliness of the external genitals and the adjacent skin 
surfaces. Diseased conditions of the rectum, the vulva, or the bladder 
should, as far as possible, be relieved. The character of the vaginal 
discharge should be learned in the antepartum examination. Discharges 
which are copious, which are yellowish or greenish, which excoriate the 
skin or are ill-odored, call for treatment of the diseased vagina and cervix. 
Douching twice daily for two or three weeks with a 1 : 5000 bichloride 
solution, or with a 2 per cent, lactic-acid solution, is usually attended 
with marked improvement. The mercurial is to be followed immedi- 
atelv with a plain sterilized-water injection to prevent absorption of the 
chemical. It is advisable that all interference within the vagina cease 
at least three days before the labor, if possible. 

In health the vaginal secretion of the pregnant woman is germicidal, 
and in normal conditions, therefore, no antepartum douching is permis- 
sible. Irrigation is not only useless, but by washing away the vaginal 
secretion and by impairing the secretory activity of the vaginal walls it 
disturbs the natural protective agencies against sepsis. 

At the beginning of labor the nurse is instructed to give the patient a 
full bath and a change of linen. The lower bowel is emptied by an 
enema and well washed out. 

The external genitals and the entire lower half of the body are rendered 
aseptic. The technique is similar to that employed for cleansing the 
obstetrician's hands. The vulvar hair may be clipped short, and finally 
a sterile compress saturated with a mild antiseptic, like boric acid or 
Thiersch's solution, or even a weak sublimate solution (1 : 5000), is 
applied over the vulva. This is worn during the first and second stages 
of labor. In hospitals the lower extremities are usually enveloped in 
sterile coverings, and the table or bed on which the delivery takes place 
is dressed with steam-sterilized sheets. 

The Lying-in Chamber. 

If practicable a large well-ventilated room with a sunny exposure 
should be selected for the lying-in chamber. It is essential that the air 
be frequently renewed and be not exposed to contamination by reason 
of defective plumbing, or other avoidable sources of impurity. An open 
fire in suitable weather aids in maintaining the supply of fresh air. 
The recent presence of septic disease in the room renders it obviously 
unsuitable. It is well to have the hangings cleansed and the entire room 
freed from accumulated dust a few days before the labor. It is not 
necessary that the room be stripped of its usual furnishings, provided 
they are clean. One or two small tables for holding instruments, steri- 
lizing-basins, hand-brushes, etc., should be available. Should an operat- 
ing-table be required in case of artificial delivery, the usual kitchen- 
table is suitable. 

Nurse's Preparations. The nurse has ready, in advance of the labor, a 
dozen towels and a half-dozen or more bed-sheets, two rubber sheets, 
large enough to cover the entire width and the greater part of the length 
of the bed. A labor pad, consisting of a square sack of cheese-cloth 
filled with surgical cotton or other absorbent material, should be pro- 
vided. It is to be placed under the patient during labor as a convenient 



234 PHYSIOLOGY OF LABOR. 

dressing for taking up the discharges. This is made three or four inches 
thick and three feet square. Instead of this, a Kelly rubber pad, such 
as is commonly used in gynecological work, may be employed. Two 
dozen lochial guards should be prepared. They are made of the same 
material as the labor pad, and about two inches thick, four inches wide, 
and ten inches long. Tail-pieces are attached at each end for fastening 
to the abdominal binder. In the absence of these, folded napkins may 
be used as vulvar dressings. Scissors for dividing, and narrow linen 
bobbin or other suitable material for ligating, the cord are provided. 
All these things are wrapped in several packages, sterilized, and not 
opened till required for use. The nurse also has ready a hand-basin 
with soap and water, another for the antiseptic solution, two new hand- 
brushes, and glycerin or vaseline as a lubricant. These, too, must be 
sterile. 

In hospital practice the patient's linen and the bed linen are steam 
sterilized at the beginning of labor. Similar precautions are to be en- 
forced as far as practicable in home confinements. Usually in the 
latter class of cases it must suffice that the linen be fresh laundered. 
When complete asepsis is impracticable the nearest approach to it that 
may be possible under the circumstances is imperative. The nurse 
should be provided with antiseptics for use during the puerperium. 

Preparation of the Bed. In family practice the patient is usually con- 
fined on a bed, or a separate cot is provided, the woman being transferred 
to the bed at the close of labor. In hospitals a table is employed for 
artificial deliveries, and this should be the rule in private practice. To 
protect the bed from soiling by the discharges, it is covered with a rubber 
sheet. Over this is spread a muslin sheet, and both are pinned fast to 
the mattress. A second rubber sheet may be spread over these, and that 
overlaid with a muslin sheet. The latter are removed at the close of 
labor, and the remaining rubber sheet after five or six days. When econ- 
omy requires, table oilcloth may be substituted for the rubber. 

For convenience the cot or bed should be so placed as to be easily 
accessible from both sides. 

Management of Labor. 

Management of the First Stage of Labor. 

Examination During Labor. 

Preparation of the Patient. The antiseptic preparation of the patient 
has already been considered. At the onset of labor the lower bowel 
is to be cleared and well washed out with an enema. If the first stage 
is prolonged the rectal injection may be once or twice repeated. Until 
the second stage begins the woman, as a rule, need not be confined to 
the bed. The progress of labor is promoted by the upright position. 
Yet too much walking may be inadvisable before the head engages in 
the pelvic brim. It may favor prolapse of an arm or the cord. 

Diagnostic Signs of Beginning Labor. Precursory signs of labor are 
frequently observed for ten days or two weeks before active pains begin. 
First to attract the attention of the patient is the lightening. This gen- 



THE MANAGEMENT OF NORMAL LABOR. 235 

erally precedes the labor by ten days or a little more. The uterus sinks 
more deeply in the pelvis and the waist line becomes smaller. Light- 
ening, however, is not constant. At the same time the pressure of the 
uterus on the pelvic viscera is increased, and bowel movements and 
evacuations of the bladder occur more frequently. 

Irritability of the bladder and the rectum becomes still more marked 
when labor begins. 

The vaginal secretion groAvs freer as labor is established, and the 
mucous plug is expelled from the cervix in the form of a gelatinous 
mass. 

A slight discharge of blood or of blood-stained mucus, the show, may 
be observed. Yet the show and the expulsion of the mucous plug are 
not always noted. 

Inquiry should be made with reference to the frequency, strength, 
and duration of the pains and the time when they began. 

Most significant of actual labor are rhythmic uterine pains, with evi- 
dence of uterine contraction during the pains as elicited with the hand 
on the abdomen over the uterus. 

Abdominal Examination. The general plan and method of the abdom- 
inal examination during labor are substantially the same as in the ante- 
partal examination. 

The size of the foetal head should be estimated as accurately as pos- 
sible by palpation, or by measurement with the pelvimeter through the 
abdominal wall and by observing how far it sinks into the pelvic brim 
or may be made to do so by suprapubic pressure. 

The stage of progress may be determined approximately in the 
abdominal examination by noting how deeply the head has sunk into 
the true pelvis. When the head has not yet engaged, if the membranes 
are still unbroken, it may usually be pressed up out of the excavation 
by placing the hands on the abdomen over the sides of the head and 
sinking the finger-tips into the pelvic brim. After engagement of the 
head the relation of the base of the skull to the pelvic inlet is made out 
by deep palpation above the pubes. The height of the anterior shoulder, 
too, is learned by palpation, and it helps in deciding how far the head 
has descended. 

The signs of a possible face presentation should be looked for in the 
abdominal examination during labor. The extension of the head which 
causes the face to present develops only after the pains begin. 

The rate and force of the foetal heart are to be noted and to be listened 
for at intervals throughout the labor. A foetal pulse below 120 or above 
150 to the minute is a probable indication of danger to the child. 

A distended bladder presents a tense fluid tumor between the uterus 
and the lower part of the abdominal wall. It is readily recognized 
by palpation over the suprapubic region. 

Vaginal Examination. Before examining internally the hands must 
be disinfected. This part of the examination aims to determine the 
condition of the vulva, the vagina, the cervix, and the bony pelvis, and 
to verify the diagnosis of foetal presentation and position as made out by 
the abdominal examination. Possible anomalies, too, of the foetus that 
may complicate the labor should be recognized. 

The resistance likely to be offered at the vulva as the head descends. 



236 PHYSIOLOGY OF LABOR. 

the lubrication of the vagina, the degree of dilatation of the cervix, the 
thickness and consistence of the cervical border, the presence or absence 
of injuries sustained in former labors are to be noted. 

For the internal examination the patient lies on the back with the 
knees drawn up. The examiner separates the labia with the thumb and 
fingers of one hand and introduces the examining finger or fingers of 
the other hand into the vagina. 

Vertex presentation is recognized by the hard and globular character 
of the cranial portion of the foetal head and by the presence of sutures 
and fontanelles. 

The position is made out by locating the sagittal suture and learning 
which end is forward, or by finding in which quadrant of the pelvis the 
smaller fontanelle lies. It is not always practicable to reach the large 
fontanelle. Great care is required to identify the anatomical landmarks 
of the presenting part, especially when they are obscured by cedematous 
swelling. Every accessible part of the presenting pole should be searched 
with the examining fingers, using firm pressure. For the diagnostic signs 
of other than vertex presentation the reader must be referred to the chap- 
ters treating of those presentations. 

Prognosis. Definite predictions as to the duration of the labor are 
seldom possible. Conditions which determine the prognosis are the rela- 
tive size of head and pelvis, the hardness of the head, the degree of 
descent, the thinness and softness of the cervix, the presence or absence 
of complications, and the strength and efficiency of the pains. But it 
is impossible to foretell with certainty the character of the pains. Yet 
the patient is entitled to such assurance and encouragement as can reason- 
ably be given. 

Patient to Remain Out of Bed. As a rule, the patient should not be 
confined to bed during the first stage. She is usually allowed the liberty 
of the room. Much walking may hinder the engagement of the head, 
and is not advisable before the head has sunk into the excavation. A 
slow labor will be accelerated by moving about and even by the standing 
or sitting position; in over-rapid labor the woman should maintain a 
reclining posture on the bed or couch. The course pursued must be 
determined by the circumstances of the individual case. 

Frequency of Vaginal Examinations. A properly conducted internal 
examination with surgically clean fingers entails practically no risk of 
infection. Yet abundant statistics have shown that the best puerperal 
results are obtained when it is possible to refrain wholly from internal 
interference. All unnecessary manipulations within the passages should 
be avoided. If a thorough antepartum examination has been made a 
single vaginal examination during the first stage of labor will usually 
suffice. This is generally advisable, to make sure that the cord or an 
arm has not prolapsed and that no other complication has developed. 
Should any irregularity occur repeated examinations may be required. 

General Rules. In the absence of complications the attendance of the 
physician during the first stage of labor is not required, except in so far 
as is necessary to keep him advised of the rate of progress. Except in 
very slow labor the physician ought to be present in the house from 
the time the dilatation of the cervix is nearly complete. Unnecessary 
manipulation of the cervix is especially to be avoided. It impairs the 



THE MANAGEMENT OF NORMAL LABOR. 237 

local resistance against infection. Lifting the anterior portion of the 
cervix over the occiput is permissible only when the anterior lip retards 
abnormally the progress of labor. Li^ht food may be allowed during 
the first stage. Pain, if severe, may be relieved by chloral. From 45 
to 60 grains may be given in doses of 15 grains every fifteen minutes in 
plenty of water. 

Management of the Second Stage of Labor. 

The management of physiological labor in the second stage, as in the 
first, should be mainly expectant. So long as all is normal the role of 
the obstetrician is little more than that of a passive observer. 

From the time the second stage is about to begin the patient must be 
in bed, and she must not, as a rule, be permitted to leave it even for 
evacuations of the bladder or the bowels. She is to be dressed in her 
usual night clothing, which is turned up and pinned at the shoulders to 
protect it from soiling. For still further protection of the patient's 
linen, the lower half of the body may be covered with a folded sheet 
fastened at the waist like a skirt. 

A slow labor may be accelerated or an over-rapid labor retarded, 
when possible by resort to simple measures. Inefficient pains are to be 
reinforced by summoning the aid of the abdominal muscles. Encourage 
the patient to hold the breath and bear down as the pain reaches its 
height. She may now and then assume a sitting posture on the edge of 
the bed. Bracing the feet and pulling upon the hands of a bystander 
or on a sheet-sling help the expulsive efforts. The sling is made by 
folding a sheet at diagonally opposite corners and twisting it loosely into 
a rope. One end is fastened at the foot of the bed and the patient pulls 
at the other. Sometimes a moderately firm abdominal binder may be 
useful. 

In too rapid labor the foregoing measures must be withheld and the 
pains retarded if necessary by the use of chloroform. 

Obstetric Positions. The choice of position in the expulsive stage of 
labor is usually left to the patient. Her comfort is promoted and the 
pains are stimulated by occasional changes of posture. For internal 
examinations either the lateral or the dorsal position may be chosen. 
The latter is generally preferred. A semi-recumbent or a sitting posture 
favors the pains owing to the influence of gravity. 

Walcher's Position. By reason of the nutation of the sacrum the 
antero-posterior diameters of the pelvic inlet are slightly increased when 
the woman lies on the back with the thighs hanging in extreme extension 
over the edge of the bed or table. (Plate XVIII.) Advantage may be 
taken of this fact, especially in difficult labor, while the head is passing 
the brim. At the outlet of the pelvis, on the other hand, the sacro-pubic 
diameter is perceptibly increased when the thighs are strongly flexed on 
the abdomen. For this reason, as well as for convenience in managing 
the birth of the head, the lateral position with the knees drawn up is 
usually to be preferred from the time the head approaches the pelvic 
outlet. 

Vaginal Examinations. In strictly normal labor there is little occasion 
to examine internally after the second stage is established, except for 



238 PHYSIOLOGY OF LABOR. 

observing the rate of progress. With practice even the degree of descent 
may be learned almost as surely and as readily by external palpation, 
and vaginal examination may, in simple labor, be omitted. By palpa- 

FlG. 204. 




Instrumental puncture of the membranes. (Ribemont-Dessaignes and Lepage.) 

ting over the suprapubic region the head can be made out till it has sunk 
deeply in the excavation. The occiput from the time it has reached the 
outlet of the bony pelvis can be felt by deep pressure with one or two 
fingers applied externally over the pelvic floor. While there is practi- 
cally no danger of infection in the vaginal examination conducted under 
proper aseptic precautions, yet the best puerperal results, as already 
stated, are attained when no internal manipulation is practised. Should 
the labor be unduly prolonged or be otherwise abnormal, repeated in- 
ternal examinations may be required to determine the cause. 

Rupture of the Membranes. The bag of membranes usually breaks 
spontaneously by the time dilatation is complete, frequently earlier. 
Sometimes it gives way at the onset of labor. In normal labor after 
the protruding bag has reached the pelvic floor, it no longer serves any 
useful purpose. If it still persists it should be ruptured artificially. 
Usually this may be done with the finger-nail while the sac of waters is 
tense during a pain. This failing, a sharp-pointed scissors, a straightened 
hairpin, or other suitable perforator, may be used. The instrument is 
sterilized and passed with its point resting on the finger-tip as a guard 
and a guide (Fig. 204.) A mere prick suffices, the membranes tearing 
readily when once punctured. 

Obstetric Anaesthesia. In obstetric as distinguished from surgical anaes- 
thesia, the object is to blunt, not wholly to abolish the sensibilities. The 
use of anaesthetics for this purpose in labor is justified on both humanita- 
rian and scientific grounds. It is not only the plain duty of the obstet- 



THE MANAGEMENT OF NORMAL LABOR. 239 

riciau to relieve the needless sufferings of his patient, but the judicious 
employment of anaesthetic agents spares her unnecessary exhaustion. It 
must not be forgotten, however, that the prolonged or too free use of 
anaesthetics is capable of harm. When pushed beyond the stage of mere 
analgesia they lessen the strength and frequency of the uterine contrac- 
tions. While seldom causing death, they are not infrequently contrib- 
uting factors in the fatal issue. Doubtless the abuse of anaesthetics may 
be a predisposing cause of sepsis, by favoring relaxation of the uterus 
and by impairing the resisting powers. They should be withheld so long 
as the pains are well borne without them. They are more especially 
called for in the latter part of the expulsive stage of labor. At the 
acme of expulsion the anaesthetic should, as a rule, be pushed nearly or 
quite to the surgical degree. 

Choice of Anaesthetics. For mere obstetric analgesia chloroform is gen- 
erally preferred. It has the advantage over ether that it is pleasanter; 
the necessary quantity, too, is less bulky, and is, consequently, more con- 
veniently carried in the obstetric bag. On the other hand, it is not so safe 
as ether, and possibly it impairs the strength of the uterine contractions 
more than does the latter agent. It is a powerful vasomotor depressant 
and its too free use may paralyze the arteries and incapacitate the heart. 
Theoretically it is especially dangerous in the third stage of labor. 

For obstetric operations in which full narcosis is required, chloroform, 
as a rule, gives place to ether. By some obstetricians the latter anaes- 
thetic is preferred for general obstetric use. It is no less manageable 
than chloroform for all obstetric purposes, and, as its advocates believe, 
it does not weaken, but rather stimulates, the uterine contractions. 

In the presence of bronchitis ether is unsuitable, owing to its irritant 
effect on the respiratory mucous membranes. In atheromatous disease 
it is dangerous, since it increases the vascular tension. Chloroform is 
to be preferred in eclampsia and in tetanic contraction of the uterus. 

Method of Administration. In obstetric anaesthesia the anaesthetic 
may safely be given by a competent nurse under direction of the 
physician. Narcosis to the surgical degree for operative intervention 
should be trusted only to a skilled medical assistant. It is desirable 
that the patient shall have taken no solid food for several hours before 
anaesthesia, especially if the narcosis is to be carried to the surgical 
degree. The head is lowered to the level of the body, if chloroform 
is to be given, all constricting bands of clothing are loosened, and the 
region of the mouth and nose smeared with, glycerin. The latter pre- 
caution is required to prevent injury to the skin by contact of liquid 
chloroform or of its concentrated vapor. The patient is requested to 
remove false teeth or other foreign bodies from the mouth. The heart 
is examined ; yet the presence of cardiac disease does not necessarily 
forbid the use of anaesthetics. Usually the shock of difficult labor, and 
especially of operative interference, is more dangerous without than 
with the anaesthetic. Yet a weak heart calls for special caution in the 
use of these agents. 

Mode of Administration. For ordinary obstetric anaesthesia a coarse 
towel is a good inhaler. It is placed over the patient's face and held by 
the middle, which is lifted six or seven inches from the face. (Fig. 205.) 
A large cone-shaped air-chamber is thus formed which insures ample 



240 



PHYSIOLOGY OF LABOR. 



dilution of the anaesthetic vapor. Instead of this an Esmarch mask 
or an Allis inhaler may be used. The anaesthetic is dropped upon the 
inhaler opposite the patient's mouth and nose. Except when complete 
narcosis is desired it is given only with the pains. To develop its effect 
by the time it is most needed, when the pain has reached its height, the 
inhalation must begin promptly at the beginning of the pain. If chlo- 
roform is used only a single drop is let fall on the inhaler with each 
breath. If ether is employed three or four drops will be required at 



Fig. 205. 




Giving chloroform with the towel-inhaler and droppiug-bottle. 

each inspiration. To increase the effect of the drug, if necessary, ask the 
patient to breathe rapidly as the inhalation begins. The administration 
is stopped by removing the inhaler as soon as the pain is about to subside. 
The drop-by-drop method should be insisted upon for either obstetric 
or surgical anaesthesia. It insures at once the greatest possible safety 
and the least discomfort in the use of either chloroform or ether. 

At the acme of expulsion, as the head is passing the introitus, the 
anaesthesia should generally be pushed to full unconsciousness. This 
not only spares the woman the severer pangs of labor, but by retarding 
expulsion and by relaxing the muscular structures of the pelvic floor it 
lessens the risk of lacerations at the vaginal outlet. 

Complete anaesthesia when required for obstetric operations during 



THE MANAGEMENT OF NORMAL LABOR. 241 

the birth or during the third stage of labor is to be managed in accord- 
ance with the well-established rales of surgical practice. 

Intraspinal Cocainization. The injection of cocaine into the spinal canal 
has been practised byKreis, of Germany, Marx, of New York, and others, 
for obstetric analgesia, with satisfactory results, but the method offers no 
apparent advantage over other anaesthetics for general obstetric use. 

The Perineal Stage of Labor. The management of labor at the acme 
of expulsion is chiefly concerned with the prevention of injuries to the 
pelvic floor. Normally the soft parts at the vulvo-vaginal outlet of the 
birth-canal yield without tearing under the gradual advance of the foetal 
head and escape important injury. Yet notable laceration of the pelvic 
floor occurs in about 35 per cent, of term labors in primipame, and nearly 
a third as often in women who have been delivered before. Rupture of 
the fourchette is the rule, and is unimportant. Minor tears may occur at 
any part of the vulvo-vaginal ring. The more important lesions are 
those of the posterior segment of the pelvic floor near the median line. 

More or less extensive laceration is frequently unavoidable in foetal 
malposition, in narrow pelvis, in relatively small vaginal outlet, and in 
undue rigidity of the pelvic floor from defective development, oedema, 
or other causes. On the other hand, at least half the pelvic-floor in- 
juries occurring in general obstetric practice are preventable by skilful 
management of the perineal stage of labor. 

Prevention depends on the distensibility of the pelvic floor and the 
smallness of the engaging circumference of the foetal head. 

The relaxation of the floor is promoted by slow and gradual delivery 
of the head, permitting the structures to stretch. Over-rapid expul- 
sion frequently results in laceration. It is seldom that the head can 
safely be permitted to escape in first labors in less than twenty to forty 
minutes from the time the pelvic floor begins to bulge. Half this time 
may suffice in subsequent labors. 

The mechanism of expulsion must be so regulated that the smallest 
circumference of the head is constantly kept in the grasp of the resisting 
girdle. Moreover, the direction of expulsion must be controlled lest the 
soft parts be subjected to too great strain by misdirection of the driving 
force. 

From the time the head approaches the pelvic floor the labor is best 
managed with the patient lying on the side, especially in primipane. The 
hips are brought close to the edge of the bed. The obstetrician stand- 
ing or sitting by the side of the bed has complete command of the rate 
and mechanism of expulsion. For some time before the oeciput appears 
at the vulvar orifice the head can be felt without examining internally 
by pressing (he fingers against the pelvic floor. The rapidity of descent 
may thus be watched till the occiput begins to protrude during the pains. 

From this period, if not for a longer time, the parts should be under 
ocular inspection. The rate of descent is moderated by moderating the 
action of the abdominal muscles by the use of chloroform, aud by direct 
pressure with the fingers held against the uncovered portion of the head. 
The head is permitted to descend only so far at each pain as can be done 
without exposing the tense structures to risk of tearing. The degree 
of tension is estimated by occasionally passing the finger just within the 
resisting vulvar ring at the height of a pain. 

16 



242 



PHYSIOLOGY OF LABOR. 



To secure delivery by the smallest circumference of the head too rapid 
extension must be prevented. Keep its long axis in the axis of the 
outlet till the equator of the head has passed. To relieve the pelvic 
floor from undue strain by misdirection of the expelling force, press the 
head firmly up into the subpubic arch as it is about to escape. 



Fig. 206. 




Regulating birth of head. 



All this may be effected without pressure upon the pelvic floor. Yet 
no harm need be done by properly guarded pressure against the head 
through the floor. With the thumb laid along one side of the vulva 
and the fingers along the other, and the palm of the hand resting broadly 
over the perineum, the head can be carried well up into the subpubic 
space and the rate and mechanism of delivery be readily controlled. 
The object of this manoeuvre, however, is not support of the floor, but 
regulation of the head movements. 

For the execution of any of the foregoing manipulations the operator 
may assume the position shown in Fig. 206 during the expulsion of the 
head. Sitting on the bed behind the patient, two or three fingers of 
each hand are held upon the head, or one hand is placed on the head 
and the other on the part of the pelvic floor which overlies the head. 



THE MANAGEMENT OF NORMAL LABOR. 243 

A basin containing the antiseptic solution should be placed near the 
bed. With a piece of sterile cheesecloth dipped in the antiseptic, the 
protruding portion of the head and the surrounding perineal surfaces 
are cleansed as often as soiled by the discharges. To protect the hands 
from soiling with fecal matter it is well to keep the anal orifice covered 
with an aseptic towel wet with the antiseptic solution during the manip- 
ulations required at the expulsion of the head. 

Episiotomy. When extensive laceration at the vaginal outlet is other- 
wise inevitable incisions may be made on either side. Episiotomy substi- 
tutes for a posterior laceration, which is often difficult of complete repair, 
incisions through less important structures, which can easily and perfectly 
be closed by suture. The incisions are made about one-third way from 
the median line posteriorly when the parts are stretched during a pain. 
They should be about 6 mm., \ inch, deep, and 2.5 cm., 1 inch, in length. 

It is needless to say that to be of service the episiotomy cuts must 
anticipate the tearing, yet the necessity for them cannot be determined, 
nor can they be effected properly till the parts are well stretched by the 
protruding head. 

During a pain a finger is passed within the vulva by the side of the 
head till a cord-like girdle is felt. A blunt-pointed bistoury is then 
slipped flatwise between the head and the tense ring. Holding it in a 
line parallel with the long axis of the mother's body the edge is turned 
outward and the girdle is cut. The incision is repeated on the opposite 
side of the vulvo- vaginal orifice. Should the mistake be made of hold- 
ing the knife in the direction of the outlet of the soft parts, instead of 
the long axis of the mother's body, it will be found after delivery that 
the tip of the blade has invaded the median portion of the pelvic floor, 
incising the very structures which the operation was intended to save. 
A strong blunt-pointed scissors may be substituted for the bistoury if 
preferred. 

After delivery the incisions are sutured. This is easily effected with 
the patient on the back, or, better, on the side. In the latter posture the 
uppermost cut is sutured first. The field is thus unobscured by blood 
which drains from the vagina over the dependent side. The position is 
then reversed for closing the other incision. 

Management of the Birth of the Trunk. On birth of the head examina- 
tion is promptly made to learn if the cord is coiled about the neck. If 
it is, the loop or loops are drawn down successively over the head. 
Should the attempt fail, which can scarcely be possible, the cord is divided 
with scissors and the trunk at once extracted. The head is supported 
with the hand, in the axis of expulsion. The delivery of the trunk is left 
to the natural forces unless reason appears for hastening the extraction. 
It is not advisable to drag the child unnecessarily from the uterus in the 
interval between contractions. As a pain comes on a finger is hooked 
in the posterior axilla from behind. The shoulder is pressed forward 
toward the child's sternum and is lifted over the perineal edge while the 
anterior shoulder still rests behind the symphysis. The posterior arm is 
now extracted and the remaining shoulder escapes under the pubic arch. 
When for any reason immediate delivery of the child by traction is 
required, the uterus should be stimulated to contract as the trunk is 
delivered, by friction with the hand upon the abdomen. 



244 



PHYSIOLOGY OF LABOR. 



Management of the Third Stage of Labor. 

From the moment the head is born one hand of the obstetrician or assist- 
ant is held on the abdomen over the uterus. So long as the uterine con- 



FlG. 207. 




Manual expression of placenta. Method of Crede. (Beers, from a photograph by H. F. J.) 

tractions go on normally after the child is expelled, only light pressure 
and no friction or other manipulation is to be used. Should the uterus 
remain too much or too persistently relaxed, contraction may be stimu- 
lated by gentle friction, moving the abdominal wall with the hand, slowly 
and in a circular direction, over the anterior wall of the uterus. If more 
active measures are called for to evacuate the uterus, the fundus may be 
grasped firmly with one or both hands. 

Crede''s Method of Expressing the Placenta. The uterus is thus watched 
for half an hour after the birth of the child. If by this time the placeuta 
has not been separated and expelled by the unaided contractions, resort is 
had to Crede' s method of expression. This is practised as follows: The 
fundus is grasped with the thumb in front and the fingers behind and a 
uterine contraction awaited. As the pain reaches its height the fundus 
is forcibly compressed with the hand and at the same time forced gently 



THE MANAGEMENT OF NORMAL LABOR. 245 

downward in the pelvis. (Fig. 207.) The efficiency of the manipula- 
tion is greatly increased if the fundus is also crowded backward to bring 
the uterine more nearly in line with the vaginal axis. Should the first 
attempt tail, it is repeated with each successive contraction till the after- 
birth is expelled from the uterus. 

If the compression is practised at the acme of a pain, and at the same 
time the woman is required to strain forcibly, the placenta is almost 
invariably expelled at the first attempt. 

Manuai Extraction of the Placenta. The uterus is to be watched with 
the hand over the abdomen for half an hour longer till retraction is fully 
established. Friction or more vigorous manipulation is applied from 
time to time only as required to maintain normal contractions. If the 
placenta still remains in the vagina or lower uterine segment, it is drawn 
down by gentle traction on the cord. When it presents at the vulva it 
is caught with the hands and careful traction made to separate the mem- 
branes should they still be partially adherent. 

Examination of the Placenta and Membranes. On expulsion the mater- 
nal surface of the placenta is carefully examined to see that no fragment 
has been left behind. The membranes are also inspected to make sure 
that both amnion aud chorion are complete. This is best done by trans- 
mitted light. As a matter of scientific interest, the weight, size, and 
shape of the placenta, the length of the cord, the site of the umbilical 
insertion, and the presence or absence of anomalies may be noted. 

Retraction of the Uterus. Should the uterus not retract promptly 
and firmly after the expulsion of the placenta, contractions are stimu- 
lated by friction with the hand on the abdomen. When more active 
measures are required, a half drachm of fluid extract of ergot may be 
given and repeated p. r. n. One or two doses of ergot are generally 
advisable when the uterus remains much relaxed, and especially after 
chloroform anaesthesia. In small doses this agent is practically harmless, 
and it fulfils more than one important indication in the management of 
the final stage of labor. It is useful as a prophylactic, not only against 
hemorrhage but against sepsis. By maintaining contractions it tends to 
prevent the accumulation of blood-clots in the uterus, to lessen after- 
pains, and to close the avenues of absorption. By limiting the blood- 
supply it promotes involution. The uterus must be watched with the 
hand on the abdomen till retraction is complete. This will require the 
attention of the physician or nurse for not less than half an hour. 

Care of the Child. On birth of the head the nurse cleanses the face 
and especially the eyes of the child, the latter best with a saturated boric 
acid solution or other mild antiseptic. The eyes are carefully dried. 
This precaution is taken for the prevention of ophthalmia, and is doubly 
important should there be reason to suspect that the vaginal discharge 
is infectious. In hospital practice a drop of a 2 per cent, solution of 
silver nitrate, Crede's solution, or better, a 10 per cent, solution of pro- 
targol, is instilled into each eye of the child at birth. This rule may 
well be carried out in family practice, and in the presence of a gonorrheal, 
septic, or diphtheritic vaginal secretion is imperative. The application 
is harmless, and is almost an absolute preventive of purulent conjuncti- 
vitis in the new-born. 

On the complete expulsion of the child steps should immediately be 



246 PHYSIOLOGY OF LABOR. 

taken to fully establish the respiratory movements. Mucus iu the pharvnx 
may be removed with the finger wrapped with a soft wet piece of cheese- 
cloth. Still better is a soft rubber tube with a rubber bulb attached. The 
mucus is sucked up into the tube. Holding the child suspended by the 
feet favors drainage from the respiratory tract, should it contain liquor 
amnii or blood drawn iuto it by premature attempts at respiration. 

The contact of cool air with the moist surface of the body, as well as 
the air-huuger created by the partial interruption of the utero-placental 
circulation, usually excites respiratory movements. Directly after birth, 
should the child not promptly begin to breathe, the action of the respi- 
ratory muscles may be stimulated by gentle flagellation over the buttocks, 
by dashing a little cold water upon the face and chest, or by forcibly 
blowing upon the face. 

The treatment of asphyxia neonatorum will be considered in the 
chapter on Anomalies and Diseases of the Xew-born Infant. 

Ligation of the Cord. The ligation of the cord should, as a rule, be 
delayed till the child is breathing freely. The infant thus gains from 
one to three ounces of blood. This post-natal afflux of blood is due to 
the force of thoracic aspiration. While of comparatively little moment 
in robust infants, it is often a matter of vital consequence in premature, 
puny, and feeble children. 

The utmost aseptic care must be observed in ligating and dividing the 
cord. Fatal infection of the umbilical vessels may result from the neglect 
of proper cleanliness. Ligature and scissors, as well as the bauds and 
everything that comes in contact with the umbilical stump, must be 
surgically clean. Before tying the cord the physician assures himself 
that no hernial protrusion has taken place into it. Firm pressure is 
applied with the thumb and fingers at the point to be ligated to press 
out the jelly of Wharton. This lessens the risk that hemorrhage may 
occur from loosening of the ligature by shrinkage of the stump. The 
ligature, which may be of narrow linen bobbin about a sixteenth inch in 
width, is then applied and tied tightly about three-fourths of an inch 
from the cutaneous junction. The cord is cut with scissors a quarter of 
an inch beyond the ligature. The end of the stump is pressed with a 
sterile cheese-cloth to see if its bleeds; should it do so it is tied again. 
The maternal end of the cord need not, as a rule, be ligated. In case of 
twins the second ligature should not be omitted, lest the undelivered child 
perish from blood-loss should the placental circulations communicate. 

The child is wrapped warmly and laid in a warm place till the neces- 
sary attentions to the mother are completed. 

Examination of Mother and Child. The physician assures himself of 
the general condition of the mother, and especially of the pulse-rate, and 
again examines the uterus with the hand on the abdomen. A careful 
inspection is made of the vulvar orifice for possible lacerations. Notable 
injuries should, as a rule, immediately be sutured. The method of suture 
will be found detailed in the chapter on the Treatment of Lacerations. 

The child is carefully examined for the possible existence of develop- 
mental anomalies. 

Vulvar Dressing. The nurse cleanses all soiled portions of the mother's 
body, bathing the external genitals with an antiseptic solution, and she 
removes all soiled linen from the patient and the bed. The vulva 



THE MANAGEMENT OF NORMAL LABOR. 



247 



is covered with an aseptic napkin which is fastened behind and in front 
to the abdominal binder when the latter is applied. Instead of the napkin 
the special dressing already described may be used. These dressings 
are burnt after once using. Their object is to receive the discharges 
and, through frequent changing, to promote the cleanliness of the ex- 
ternal genitals. 

Abdominal Binder. A moderately firm bandage about the abdomen 
adds to the comfort of the patient after labor. It may be fairly tight 

Fig. 208 




Abdominal binder. 

for the first twelve hours for support. After that time it should be 
slightly looser. This is discarded by the time the woman leaves the bed 
or earlier. The binder is best made of strong unbleached muslin. It 
should be wide enough to reach from the great trochanters to the ensi- 
form appendage, and long enough barely to permit the ends to overlap 
after encircling the body. It is pinned with shield-pins in the median 
line in front, and then made tight by pinning a fold at each side (Fig. 
208). If compresses are used under the binder, one should be placed 
above and one on each side of the uterus. 

Final Duties. Before leaving the physician again takes note of the 
condition of the mother, and examines the child to see that all is normal. 
The nurse is given full instructions with reference to the care of the 
mother and child. One or two doses of ergot and a prescription for 
relieving after-pains are left, to be used if required. 



PART IV. 

PHYSIOLOGY OF THE PUERPERIUM 



CHAPTER X. 

THE PUERPERAL STATE. 

Definition. By the puerperal period is meant the time which elapses 
after childbirth during which the changes observed in the course of labor 
and pregnancy are being effaced and the body is returning more or less 
approximately to the state in which it was before impregnation. But, 
since these progressive and retrogressive alterations chiefly involve the 
generative organs, we may leave out of consideration the general consti- 
tutional changes, and for practical purposes limit our definition so that 
the puerperium may signify " that period after labor in which the geni- 
talia are regaining the condition proper to those of the non-gravid 
woman." In the case of women who have previously borne children, 
the condition reached at the end of the puerperium should, except as 
regards the inevitable local changes, be that observed before the last 
pregnancy. In the case of primiparse, the previous nulliparous condi- 
tion is never regained. Certain changes have taken place in the genitalia 
and in the abdominal walls which are permanent and which are accom- 
panied with more or less certain indications that at least one labor has 
occurred. 

The puerperium may, therefore, be said to begin immediately after the 
delivery of the placenta and to end with the complete involution and 
regeneration of the internal genitals. Exact anatomical observations 
have proved that the processes involved usually take about six weeks. 
Between individual cases the variations may be considerable. It is inter- 
esting to note that the limits of the period had been established long 
before our modern scientific methods of examination were known. It 
is not hard to see how the older obstetricians made so correct calculations. 
Experience had taught them that after six weeks the normal functions of 
the non-impregnated genitalia — namely, menstruation and conception — 
could begin again. It is true that in nursing women menstruation rarely 
occurs at so early a date, but it is a well-known fact that it is possible for 
them from this time forward to conceive again, the possibility becoming 
greater every month. 

Introductory Remarks. Pregnancy, labor, and the puerperal state are, 
under ordinary circumstances, natural processes, but in all of them the 
physiological borders so closely upon the pathological that it is extremely 
difficult to draw a hard-and-fast line between the two. Of necessity, 

(249) 



250 PHYSIOLOGY OF THE PUERPERIUM. 

then, in descriptions of the so-called normal puerperium and its man- 
agement, it is almost impossible to avoid touching upon certain minor 
pathological conditions, which are not severe enough to bring about any 
serious results. 

The puerperal woman has been aptly compared to a person suffering 
from a recent more or less severe wound. Provided the patient has been 
in a normal condition previously, and that the wound be not too severe 
and can be kept surgically clean, beyond the weakness caused by pain, 
loss of blood, and a certain amount of nervous shock, there is nothing to 
interfere with a speedy recovery. But once allow infectious material to 
enter the wound, a series of pathological processes ensue which materially 
alter the features of the case. In the puerperal woman Ave have to deal 
with open wounds extending over a large surface, a contused condition of 
the genitalia, exhaustion following labor, and a condition of more or less 
marked nervous shock. Here, then, we have a condition physiological, 
perhaps, but easily transformed into a most serious pathological state. 
Everything, it may be said, is present which would render the occurrence 
of infection peculiarly easy. The open wounds and contused surfaces offer 
a decreased local resistance; the lochial discharge and the blood-clots in 
the uterine sinuses at the placental site form excellent media for bacterial 
growth. The very number of the small lacerations increases the chances 
that any poison introduced may find a congenial nidus where it can pro- 
duce a localized pathological process or from which it can spread and 
infect the whole system. Added to this we have the general weakness 
and exhaustion of the whole body, which offers decreased resistance to 
the attack of any pathogenic agent. Thus it will easily be seen that for 
the bringing about of a normal puerperium prophylactic measures play 
the most important part, and when complications arise after a normal 
labor the obstetrician has always to ask himself how far he has been 
responsible for their existence and in what way his technique has been 
faulty. Nothing can be more satisfactory to the physician than to see 
his patient who has just undergone perhaps the most severe trial and 
suffering which she has ever experienced, regaining almost perceptibly 
from hour to hour her former health and strength, and nothing is more 
painful to watch than the course of a puerperal infection, which if not 
fatal is always serious, and may leave behind it irreparable damage, 
especially when he has to confess that the cause for the whole trouble 
probably lies in some apparently trivial error, either of omission or com- 
mission, which has occurred in the course of what should be a physio- 
logical process. 

We shall now take up in detail the changes which take place in the 
genitalia during the puerperium. 

Outlet and Vagina. In primiparse the hymen and the fourchette are 
almost invariably torn, and such tears are of no import. Deeper lacera- 
tions, especially those extending into the perineal body or into the bowel, 
though at times not preventable, must always be considered as patholog- 
ical. The tear in the hymen is usually stellate, and after in volution traces of 
the membrane are found in the small bodies surrounding the outlet, the so- 
called carunculse myrtiformes. The whole vagina has been dilated during 
labor, but, though in all cases microscopic lacerations probably occur, the 
elasticity of the tissues of the canal generally prevents the occurrence of 



THE PUERPERAL STATE. 251 

any serious injury. The external and internal parts, however, are always 
more or less contused, cedematous, and hypersemic. Small lacerations usu- 
ally heal spontaneously, if kept clean. The more serious tears, when coap- 
tation of the wounded surfaces does not occur spontaneously, if neglected, 
heal chiefly by granulation and cicatrization, and may leave extensive 
areas of scar-tissue behind them. Lacerations in the anterior wall of the 
vagina may give rise to troublesome vesico-vaginal, urethro- vaginal, or 
even vesico-urethro-vaginal fistulse. A vesico-vaginal fistula at the site 
of the vesical trigone is an especially troublesome complication. Lacera- 
tions in the posterior vault and posterior wall may or may not commu- 
nicate with the peritoneal cavity or rectum. Superficial tears in this 
region are not unusual. An overstretching of the outlet or lacerations 
which have separated some of the fibres of the levator ani muscle are 
frequently found. Fortunately, in many cases it will happen that at the 
end of the puerperium nature has rectified this condition. But in not a 
few instances the function of the levator ani is permanently impaired. 
The anterior fibres of this muscle furnish the chief support of the outlet; 
acting from the two rami of the pubic bone they pull the vaginal orifice 
upward and forward away from the direct line of intra-abdominal press- 
ure. If, therefore, the function of these fibres be put in abeyance pro- 
lapse of the vaginal walls and descent or prolapse of the uterus must 
almost certainly follow. The treatment of serious tears or overstretching 
of this muscle has been discussed elsewhere. 

Normally the small tears of the vagina soon heal promptly, sometimes 
by first intention, despite their continuous lochial bath. More or less 
extensive cicatrices may be left behind to mark their previous situation. 
The vagina becomes smaller and narrower, and from being smooth be- 
comes wrinkled, though the rugae are never so deep or as well marked as 
in the primipara. The swollen, succulent, and hypersemic condition grad- 
ually subsides. Should there occur no unusual or pathological amount 
of cicatrization, the vagina at the end of the puerperium will be found 
roomier than in the primipara and somewhat shorter. The outlet will 
be considerably larger than before, but should be still held up closely 
under the pubic arch by the action of the levator-ani muscle and be 
oapable of effective contraction and narrowing by the joint action of this 
muscle and of the constrictor cunni. The rima vulvae should be almost 
entirely closed. 

Uterus. The uterus as a whole immediately after labor is said to weigh 
from 800 to 1000 grammes. It measures from 15 to 20 cm. in length, 
and from 11 to 12 cm. in breadth at the level of the Fallopian tubes. 
The wall of the upper uterine segment measures 3 to 4 cm. in thickness. 
The uterine cavity (sound measurement) is 15 to 16 cm. in length. The 
following table shows the comparative measurements of virginal and 
muciparous uteri, made by Sappey, Eichet, and Henning: 

Virgin. 

Length of uterus 5.8 cm. 

Width 3.8 " 

Thickness 2.1 " 

Vertical diameter of cavity . . . 4.5 " 

Capacity of the uterus 

Length of entire organ in young women 

Weight of virgin uterus .... 40 grammes 



Nullipara. 


Multipara 


6.2 cm. 


6.8 cm. 


3.9 " 


4.2 " 


2.3 " 


2.5 " 




6.1 " 


to 3 " 


3 to 5 ' • 


5.6 " 





252 PHYSIOLOGY OF THE PUERPEEIUJL 

It will be seen from these figures that the parous is in all its dimen- 
sions somewhat larger than the virgin uterus. The cervical portion is 
also shorter than in the virginal condition. The arbor vita? is partially 
effaced. The sound measurements of the uterus during the puerperium, 
as given by Hansen, are as follows : 

Tenth day, 8 to 13.5 cm. 

Fifteenth day, 8.3 to 11.5 cm. 

Third week, 7.5 to 10.5 cm. 

Fourth week, 7 to 9.3 cm. 

Fifth week, 6.5 to 9 cm. 

Sixth week, 6.2 to 9. 1 cm. 

Eighth week, 5.6 to 8.5 cm. 

Tenth week, 5.4 to 7.5 cm. 

Immediately after the expulsion of the placenta the fundus of the 
uterus should be felt as the upper extremity of a globular body half-way 
between the umbilicus and the upper border of the symphysis. In about 
six hours, however, it will be found to have risen again and to be about 
on a level with the umbilicus, or usually about 11 cm. above the sym- 
physis, the greatest breadth of the uterus at the time being about 
10 cm. From this time it diminishes rapidly in size, so that by the 
ninth, tenth, or twelfth day the fundus should be found at the level of 
the upper border of the symphysis, the body of the uterus lying entirely 
in the true pelvis. The uterus should at this time be somewhat ante- 
verted or anteflexed. Involution also goes on in the cervical canal and 
in the portio vaginalis. Immediately after birth the cervix hangs clown 
into the vagina, as a thin, flaccid ring, in marked contrast to the firmly 
contracted uterine body above. Gradually the tissues regain their elas- 
ticity and the regenerated portio vaginalis contracts. At first the cer- 
vical canal measures 7 cm., but already on the second day contraction has 
begun. At the beginning of the second week the portio vaginalis has 
about regained its usual size and consistence. 

Uterine Muscular Tissue. During pregnancy the muscle cells are greatly 
increased in size, attaining from ten to twelve times their former length 
and from three to five times their normal breadth. Although the fact 
was formerly much disputed, it is now generally recognized that there is 
also a new formation of muscle cells. After labor, therefore, we have 
an enormous amount of tissue which disappears, the uterus losing in the 
first two weeks about a pound in weight. This takes place as a result 
of fatty degeneration. It is a well-known fact that if any organ or part 
of an organ in the body is deprived of nourishment it undergoes fatty 
degeneration and subsequently at least partial absorption. Now, the 
stroug contractions of the uterus lessen the blood-supply, and by cutting 
off the nutrition cause the degeneration of the superabundant amount of 
tissue. It is clear, therefore, in the absence of sufficiently powerful con- 
tractions the uterus cannot reach, at least within the normal time, the 
appropriate state of involution. 

It is a disputed point whether or not these enlarged muscle cells totally 
disappear and are replaced by newly formed cells. Some authorities hold 
that the majority, if not all, of these large cells are entirely destroyed, 
and that the involuted uterus is made up of new cells. The weight of 
the evidence, however, seems to favor the view that the large cells undergo 



THE PUERPERAL STATE. 253 

degeneration only up to a certain point, and that the process then conies 
to a standstill, so that the atrophy ceases as soon as the cells have reached 
their original size. It is certain that they do not become quite as small 
as formerly, or if they do some of the newly formed cells must persist, 
since the parous uterus is always somewhat larger than that of the virgin. 

The connective tissue undergoes similar changes. 

Uterine Vessels and Nerves. The bloodvessels, lymphatics, and nerves 
have participated in the general growth during pregnancy, and have 
increased in length and diameter. The arteries have correspondingly 
thicker walls, except in the case of those which run in the decidua, where 
the walls are thinner than usual for vessels of so large a size. On 
account of their length they take a tortuous course, and many communi- 
cate directly with veins. At the placental site some of the sinuses have 
been closed by thrombi in the last month of pregnancy. Those which 
remain open till after delivery are closed by the contractions of the uterus, 
which bring their walls in close apposition, causing the formation of a 
clot, which later on undergoes organization. Other vessels of the uterus 
undergo pressure atrophy, and are finally obliterated, the obliteration in 
some cases being brought about by excessive growth of their walls. In 
examining sections of parous uteri, these vessels, with much thickened 
coats, are often met with and in many cases undoubtedly persist after 
the process of involution is finished. 

Uterine Mucosa. The mucosa, which measures only a few millimetres 
in thickness, may be divided for purpose of description into two layers. 
The inner, which is in contact with the decidua, is very poorly provided 
with glandular elements, and on section seems to be made up almost 
entirely of decidual cells with small round mononuclear cells resembling 
lymphocytes scattered through it. This has been termed the " cellular 
layer." The outer layer is composed entirely of convoluted glands, 
which give to the sections a honeycombed appearance. This layer is 
known as the u honeycomb" or u glandular " layer. The inner or 
cellular layer is for the most part thrown off along with the decidua. 
Of the outer or glandular layer, a portion remains behind, and from it 
the new mucosa or endothelium is formed. The process is strongly sug- 
gestive of one of transplantation. The tubes of the glands have retained 
their epithelium, so that we have, as it were, islands from which the regen- 
eration spreads, so that what at first was apparently a raw surface is 
gradually covered. The tissue which is not utilized in the process under- 
goes fatty degeneration and is gradually thrown off. 

Patches of pigment are found for a considerable time in the endome- 
trium, especially at the seat of the placenta, where they persist longer 
than elsewhere. The placental site is probably the last to receive its 
protecting coat of epithelium. This is doubtless due to peculiarities in 
the histological structure of the glandular layer at this point, very little 
trace of it being seen. 

By the end of the fifth or sixth week the new endometrium is probably 
complete. 

Tubes, Ovaries, and Parametrial Tissues. During pregnancy the tubes 
are elongated and somewhat thickened, the parametrial tissues are also 
hypertrophied, and all the adnexa are hypera?mic. After delivery this 
hyperemia subsides and a physiological atrophy takes place until the 



254 PHYSIOLOGY OF THE PUERPERIUM. 

organs regain approximately their original size. The corpus luteurn, 
which may be still present after labor, gradually shrivels, and as time 
goes on becomes more deeply embedded in the ovary until it finally dis- 
appears or can be demonstrated only by the microscope. 

Lochia. For the source of the lochia we have not far to look when we 
consider that we are dealing with an extensive open wound and with the 
removal of a comparatively large quantity of detritus from the tissues in 
the course of involution. From an open wound comes at first blood, and 
similarly in this case we have for the first few hours and days a bloody 
fluid, the lochia rubra vel cruenta. The microscopic examination of the 
secretion shows numerous red blood-corpuscles, portions of clots, and of 
decidual shreds. After a few days the secretion still stains the napkins 
a reddish-brown color, but the fragments have a pale yellowish appear- 
ance. The lochia after a week contain serum mixed with the coloring 
matter of the blood, together with scattered flat epithelial and cylindrical 
cells, and are called lochia serosa. As the external wounds gradually take 
on granulations, leucocytes are mixed with the secretion. These cells 
are at first few in number, but increase until after the end of the second 
week; the secretion is purulent, the lochia alba vel purulenta. These 
changes take place gradually; approximately it may be said that the 
lochia rubra appear for three days; the lochia serosa from the third to the 
eighth day contain much albumin, mucin, fat, chlorides, and phosphates, 
their reaction being alkaline. In the second week the lochia alba appear, 
containing leucocytes, fat, cholesterin, and a few connective-tissue cells. 
The normal acid secretions of the vagina finally give to the lochia an 
acid reaction. The flow from the uterus itself should always be sterile, 
and for the first day or two the lochia normally contain no micro-organ- 
isms. It is not, however, unusual for their presence to be demonstrable 
in the secretion later, and provided that they come only from the vagina 
their occurrence must not be considered abnormal. 

The amount of the lochia has been variously estimated by different 
authors. Gassner, quoted by Winckel, gives the following figures: 

Lochia cruenta 1000 grammes. 

Lochia serosa 260 " 

Lochia alba 205 " 

The amount necessarily varies in different cases. Where there is faulty 
involution the lochia are more profuse. In nursing women the duration 
of the flow is generally shorter than in the cases in which the women do 
not suckle their children. The discharge diminishes gradually, and 
usually disappears entirely between the second and the sixth week. 

After-pains. The changes going on in the inner genitalia are brought 
about principally by contractions of the uterus, occurring at more or less 
regular intervals, and which are sometimes appreciated by the patient, 
since they produce what are called u after-pain s." It is to be noted 
that primiparse seldom complain much of these pains, so that when they 
are at all marked some pathological process is generally to be suspected. 
In multipara? they occur quite frequently, but can usually be easily con- 
trolled. The intensity of the after-pains is in inverse proportion to the 
strength of the uterine contractions during parturition, so that, as a rule, 
patients who have had a speedy, almost painless, labor, are apt to suffer 
more during the puerperium. 



THE PUERPERAL STATE. 



00 



Urine. Notwithstanding the great activity of the skin after labor the 
amount of urine excreted by the kidneys should be rather more abundant 
in quantity than under ordinary circumstances. The woman may, how- 
ever, pass but little urine at first, and after the first five or six hours the 
bladder may become much distended. Three factors contribute to bring 
about this accumulation: (1) The amount of urine passing into the blad- 
der from the kidneys is greater than usual. (2) The expulsion of the 
contents of the uterus, the child, placenta, and liquor amnii, has removed 
quite a large mass from the maternal body, as a consequence of which 
the intra-abdominal pressure is decreased and the abdominal walls are 
flaccid, the bladder being thus allowed more room to expand and less 
resistance being exerted to its distention. (3) The woman, finding, per- 
haps, that a few drops of the urine trickling down over small lacerations 
of the outer genitalia cause a disagreeable smarting sensation, may thus 
be led almost unconsciously to retain her urine as long as possible. 

The increase in amount seems to be mainly in the water, the urine 
being of rather a lower specific gravity than usual. The total amount 
of urea excreted is practically unchanged, the increase, if any, being quite 
insignificant. Sodium chloride is present in relatively larger amounts; 
phosphoric and sulphuric acids are both somewhat increased. Peptone 
is usually found in the urine. Its presence bears probably some relation 
to the involution of the uterus, since it is found from the second half of 
the first day after labor to the seventh day. Winckel reports a case of 
Porro's operation in which it was absent. Acetone is said to be a con- 
stant constitutcnt of the urine of puerperal women. Albumin may be 
found in some cases, due to a temporary renal hyperemia, but its presence 
must be considered abnormal, and its persistence is always of grave 
import. The presence of sugar in the urine for a few days is not neces- 
sarily a serious symptom, and is commonly to be explained by reabsorp- 
tion of milk-sugar from the mammary secretion. Its occurrence is not 
rare and is more especially frequent in cases in which there is distention 
of the breasts either from over-secretion or from failure on the part of 
the child to utilize the proper amount of milk. 

Bowels. The bowels are apt to be sluggish at first, and do not move 
naturally for several days. This may be accounted for principally by the 
lessened intra-abdominal pressure. The fact that the woman receives only 
a liquid diet, and that the watery parts are given off in a great measure 
through the skin, and in the milk, urine, and lochia, leaves little solid fecal 
matter to be evacuated, especially if the bowels have been well cleared 
out before labor. That lessened peristalsis does not play much part in 
causing the constipation is proved by the fact that the excreta are passed 
along the bowels, the rectum being in many cases enormously distended. 

Temperature. In view of the extensive changes which are going on in 
the body and the great amount of material to be absorbed and eliminated, 
it certainly would at first sight appear extraordinary that the process is 
not accompanied by grave pathological symptoms. Under ordinary cir- 
cumstances it might be expected that the absorption of a pound or more 
of tissue which undergoes retrogressive metabolism would certainly give 
rise to a high temperature. Careful observations, however, based upon 
long experience have proved beyond doubt, that normally the puerperium 
passes without fever. In the past it was an established belief that the 



256 PHYSIOLOGY OF THE PUERPERIUM. 

puerpera during the first few days, especially when the secretion of milk 
began, must have fever. This idea was rendered more plausible by the 
fact that not a few women, especially primiparee, undergo no little emo- 
tional excitement. The pain which accompanies the secretion of milk, 
some difficulty in coaxing the child to nurse, the soreness experienced 
when it seizes the nipples, all tend to excite and worry the mother, espe- 
cially if she be a primipara. The physician or nurse finds the pulse 
quickened, the face red, and the patient complaining of exhaustion, and, 
possibly, of severe headache. Surely under these circumstances it was 
not unreasonable to say that fever was present. The clinical thermom- 
eter, however, has upset entirely this opinion. 

There is No Such Thing as Milk Fever. The secretion of milk of itself, 
be the breast ever so hard or swollen, goes on in innumerable cases with- 
out a rise of temperature. Careful observation has also proved that 
retention of milk does not cause fever. Elevations of temperature may 
be caused by trifling circumstances, but if the rise is not very slight and 
quite transient we are in face of some pathological factor. Zweifel holds 
that a temperature of 37.6° C. or 37.7° C, 99.5°-100° F., in the axilla 
is always pathological. If the puerpera has not been subjected to harmful 
influences she will have no fever. Milk fever is traumatic fever, and trau- 
matic fever means infection. 

It is hardly possible to repeat this fact too often, for if it is neglected 
valuable time may be wasted in vain hopes, when a rigid search might 
reveal the pathological cause and enable us at once to institute measures 
to rectify the conditon. 

The Pulse. After completion of the third stage the pulse usually decreases 
very markedly in rapidity. The first sound of the heart often takes on 
a soft murmurish tone. This change may not occur at once, but usually 
takes place within the first twelve hours, the rate falling to 60 or less, 
and in exceptional instances to 40 per minute. A pulse as low as 34 has 
been recorded. The arterial tension is not increased. The duration of 
this slowing of the heart varies in individual cases, being usually in 
direct proportion to the lowness of the rate. No completely satisfactory 
explanation of this phenomenon has been arrived at. Doubtless the 
complete physical and mental rest, coming as it docs after a period of 
anxiety and suffering, plays an important part, although it does not by 
any means of itself afford a sufficient explanation. Olshausen thought 
that the absorption of fat and the presence of fat emboli could account 
for the slowing of the pulse. It is possible that the stasis occurring in the 
abdominal veins may account in part for the slowing of the circulation, 
or that the shutting off of a great mass of blood going to the uterus, by 
relieving the heart of some of its work, may act in the same way. Both 
these theories, however, are rendered somewhat unsatisfactory from the 
fact that the slowing of the pulse also occurs after early abortions, in 
which the shutting off of the utero-placental circulation or stasis in the 
abdominal veins could hardly figure as relieving the heart of much extra 
work. The same objection applies to the attempt to find an explanation 
in the increase of the pulmonary capacity as a consequence of the expul- 
sion of a large abdominal tumor. It is only natural that the rate and 
character of the pulse of the puerpera may be temporarily influenced by 
very trifling causes. 



THE PUERPERAL STATE. 257 

The Respiration. At one time it was held that the pulmonary capacity 
was increased after labor. Modern investigations, however, do not bear 
out this assumption. Out of 50 cases examined by Vagas the pulmonary 
capacity was found to be the same as before labor in 26 cases. It was 
increased in 17 and decreased in 7 cases. The character of the respira- 
tions is not markedly altered. 

The Skin. Formerly the u puerperal sweats ?? were well known. They 
were noted especially during sleep and often attended by what was 
thought to be a characteristic odor, which was probably dependent upon 
the presence of fatty acids, and often accompanies severe sweating. The 
older obstetricians welcomed their appearance and regarded their absence 
as a somewhat ominous sign. At the present day, now that the close, 
overheated lying-in chamber has given place to the cool, well-ventilated 
room, one rarely sees drops of sweat upon the forehead of the puerperal 
woman. 

The skin of the abdomen shows shining whitish or reddish lines, which 
at a later date become quite white, the lineae albicantes. These are usually 
arranged in the form of crescents running from the groin toward the 
umbilicus, and are far more numerous and more deeply marked below the 
navel than above it. They are caused by overstretching of the skin 
during pregnancy and the subsequent replacement of part of the corium 
by scar tissue. Areas of pigmentation which have appeared on the face, 
abdomen, around the nipples, and elsewhere on the body during preg- 
nancy, gradually begin to fade during the puerperium, although, as a 
rule, they do not entirely disappear. The areolae of pigmentation around 
the nipples, more marked in brunettes, grow less conspicuous, but are 
never entirely obliterated. 

The Digestive Apparatus. Just as the excretions of one organ serve to 
nourish other organs, it is not improbable that a considerable amount of 
the products of the involution going on in the genitalia is utilized as food 
for the other tissues of the body; but that all are not so used is proved 
by the fact that peptone can be demonstrated in the urine. The power 
of the digestion of solid food is for a time enfeebled. Thirst is usually 
present, and is easily accounted for by the great drain of water from the 
body in the increased perspiration, the lochia, the milk, and the urinary 
secretion. The sluggishness of the bowels has already been referred to. 

Loss in Weight. As elimination exceeds ingestion, it is self-evident 
that the puerperal woman must lose considerably in weight. The amount 
lost has been variously estimated as from one-twelfth to one-eighth of 
the entire body-weight in the first seven days. Non-nursing women and 
primiparse lose less than nursing mothers and multipara?, the loss being 
actually, though not relatively, greater in proportion to the normal body 
weight. Under ordinary circumstances the diminution should cease at 
the latest by the ninth day. 

Lactation. The breasts for a short time after labor afford a secretion 
similar to that which they contained during pregnancy. This early milk, 
or, as it is called, "colostrum," is a whitish or faint yellowish, viscid 
fluid resembling milk, but differs from it chemically in being richer in 
sugar, fat, and salts. It seems to have a laxative effect upon the child, 
and sweeps away the meconium from the bowels. This action has been 
attributed to the separate or collective effect of the excess of the several 

17 



258 PHYSIOLOGY OF THE PUEBPERIUM. 

ingredients. One author advances the view that it acts by its indigesti- 
bility. Microscopically it differs from milk in containing the so-called 
" colostrum " cell, which is nothing more nor less than a large epithelial 
cell studded with fat globules. The fat globules of the colostrum are 
not as uniform in size as those of milk. 

The true milk secretion begins about the second day or occasionally on 
the third day. The breasts, which have already enlarged during preg- 
nancy, become still more tense and swell to such a degree that they are 
often very sensitive, and may be the seat of considerable paiu. The pain 
and emotional disturbance, especially if there is trouble in making the 
infant take the breast, may give rise to a slight elevation of temperature. 
The so-called milk fever, a myth of the prebacterial stage of medical 
knowledge, has been discussed. Microscopically, human milk is seen to 
consist of minute oil globules of rather uniform size, floating in a trans- 
parent, colorless plasma. Human milk, like that of all other animals, 
is an emulsion. The emulsifying agent is an albuminoid, the casein. 
The plasma contains milk-sugar and inorganic salts. The fats, sugar, 
and casein are produced from the cells of the acini of the glands. The 
liquid portion, the plasma, is obtained from the blood. As regards its 
chemical constitution, milk varies in different women or at different times, 
and even in the two breasts of the same woman. The approximate chem- 
ical composition of rich human milk is shown in the following table : 

Water 38 9 per cent. 

Solids 11-1 

Casein 3.82 

Fat 2 66 " 

Milk-sugar . 4.36 

Inorganic salts 0.14 

The quantity of milk secreted varies also in different women and at 
different times. During the first three days the whole amount may be 
between 50 and 200 cc, but the quantity rises rapidly, until by the 
ninth day 400 to 450 cc. are being secreted daily. The character of 
the milk is altered by various conditions of the mother. Certain medi- 
cines when given the mother are given off almost unchanged in the milk 
secretion, and may seriously disagree with the nursing child. It has 
been found also that mental or physical disturbance in the mother may 
so alter her milk so as to render it unwholesome. The reappearance 
of the menstrual function makes a change in the character of the milk. 
The disturbance, however, is usually temporary, and subsides immediately 
after the menstrual period. 

In women who do not suckle their children milk secretion goes on for 
a couple of days; during this time the colostrum corpuscles gradually 
decrease, but again show a relative increase. The breast undergoes a 
physiological atrophy; the secretion gradually becomes less, until at the 
end of from fourteen to sixteen days it practically ceases. 

The period of lactation may be said to last for almost one year, though 
at the end of the sixth or eighth month the quantity and quality of the 
milk secreted often begin to fall off. Some women nurse their children 
far into the second year, but the nutritive properties of the milk are of 
necessity very poor. 



THE PUERPERAL STATE. 259 

Care of the Puerperal Woman. 

Kenieinbering that the puerperiutn after a properly conducted labor is 
a natural condition, it remains for the obstetrician, while abstaining stren- 
uously from meddlesome interference with nature, to take such precau- 
tions as shall prevent the physiological from merging into the pathological 
upon which it so nearly borders in these cases. The main treatment may 
conveniently be discussed under three heads : (1) proper nutrition; (2) 
absolute rest of body and mind; (3) proper hygiene with aseptic treat- 
ment of the wounded parts. 

Nourishment. Liquids should be given for the first two or three days. 
Milk is the best food, but an occasional cup of beef-tea, clear soup, or 
weak cocoa is often very grateful to the patient. For thirst, water must 
be principally given, but a cup of tea, if the patient expresses a desire 
for it, will do no harm. After the third day a gradual return to the 
usual diet may be made. After the first week extra nourishment, prefer- 
ably in the shape of milk between meals, should be allowed. Malt liquors 
or wines are usually unnecessary; if, however, the woman is habituated 
to a moderate use of them they may be allowed in very small quantities. 
The patient's own tastes may be consulted and will usually serve as a 
guide for the diet to be given, provided nothing too heavy or manifestly 
indigestible be desired. If the patient is fond of eggs they form a very 
nourishing food, and can be given to her prepared in a number of different 
appetizing forms. 

Rest. The puerpera should have complete bodily and, what is just as 
important, absolute mental rest. After remaining quiet for a few minutes 
after the completion of the third stage of labor, the mother usually desires 
to see her child. This wish may generally be gratified; but as soon as pos- 
sible after the linen has been changed and she has been made comfortable 
the room should be moderately darkened and the patient should be left 
to sleep. After she awakes the infant may be put to the breast for a few 
minutes. For the first two or three days the woman should be kept flat 
on her back, with the head only a little raised on a small pillow. When 
nursing the infant she may assume the lateral position, if this is found to 
be more convenient, but all sudden changes of position, especially the 
sudden arising into a sitting or standing posture, for the first few days 
must be strenuously avoided. Neglect of such precautions has not 
infrequently been followed by fatal syncope. After the uterus has had 
time to contract firmly and the sinuses have been permanently closed, 
the danger becomes minimized; but it is, nevertheless, advisable to avoid 
any sudden change of posture for some time. It is well to secure 
greater safety, even at the expense of a little discomfort, and for the 
first few days not to allow her to rise even to pass urine or to have a 
movement from the bowels; for this purpose she should be induced to 
use the bed-pan. It is not uncommon for patients to experience con- 
siderable difficulty in passing the urine while in the recumbent position ; 
this, however, may generally be obviated by applying a warm wet aseptic 
compress to the vulva. Occasionally the sound of a little water trickling 
into the bed-pan will have a salutary effect. If no urine has been passed 
for over eight hours, and the various simple expedients have failed to 
cause the patient to urinate voluntarily, she will have to be catheterized. 



260 PHYSIOL OGY OF THE P UEBPERIUM. 

Glass catheters are cheap, and if broken can readily be replaced. They 
are better than those of other material, since they can easily and certainly 
be kept aseptic. Before and after use they should be thoroughly cleansed 
with hot water, and in the iuteryals may be kept in 1:40 carbolic-acid 
solution. Before being used the catheter is rinsed thoroughly in sterilized 
water in order to free it from the carbolic acid. Catheterization demands 
complete exposure of the parts, and as thorough asepsis as possible. 
Without the former the latter is impossible, and catheterization under 
the bedclothes is inadmissible. A little tact will generally suffice to 
overcome the objections of any patient who has been accustomed to the 
old method and who may feel a little sensitive about the procedure. The 
external genitals, more particularly the parts immediately around the 
meatus, should be cleansed from lochia and the labia be held apart while 
the catheter is being introduced. These precautions are necessary every 
time catheterization is employed if we wish to provide against the chances 
of setting up what may probably be a serious cystitis. When it has been 
found necessary to draw off the urine the catheter should be used once, 
and as soon as the bladder begins again to be moderately distended the 
patient should be urged to make several efforts at emptying the bladder 
spontaneously. If she is unsuccessful in her attempts she should not 
be allowed to go more than eight hours without having her bladder 
emptied. In a few cases repeated catheterization will be forced upon us, 
but we should not fail to do our utmost to obviate the necessity as soon 
as possible. 

The bowels should be opened by the third day. This is best accom- 
plished, if it does not occur spontaneously, by some simple enema, pref- 
erably of soap and water. Should this prove ineffectual, and large 
masses of feces be present in the rectum, three or four ounces of sweet 
oil may be injected carefully and allowed to remain for half an hour, 
after which another simple enema may be given. A dose of castor oil, 
giyen in capsules if preferred, will generally aid very much in bringing 
about a satisfactory result. Care should be exercised in giving medicines 
to the nursing woman, since many drugs, notably the minerals and rhu- 
barb, are excreted partially in the milk secretion, and may thus disturb 
the digestion of the child. Salts are not recommended in these cases, 
because they are supposed to diminish the secretion of milk; in many 
instances, however, especially when there is abundance of milk, they seem 
to act well. 

Perfect mental rest is of the greatest importance to the puerperal 
woman. A short nap will do more to strengthen and invigorate her than 
any amount of congratulations on the part of relatives and friends. With 
the exception of the husband or mother, who may be allowed to remain 
if their presence seems to quiet and comfort the patient and does not 
interfere with her rest and sleep, all other visitors should be rigorously 
excluded. The child should not be kept near enough to disturb her 
by its cries, and should under no circumstance be allowed to sleep in 
the same bed with its mother. If this rule w r ere always carried out the 
rate of mortality from " overlying" would be considerably diminished. 
Until she has regained her strength the patient should be kept free from 
all household cares. These should be delegated to the nurse or some 
other competent person. The anxieties and troubles of others should not 



THE PUERPERAL STATE. 261 

be brought to her for sympathy. Excessive joy or grief has not infre- 
quently caused death in puerperal women. Mental emotion has been 
known to bring about inhibition of the contractions of the uterus, and 
thus to cause dangerous flooding, and even if it does not produce serious 
symptoms, excitement always interferes with the proper progress of 
convalescence. 

The Lying-in Room, whenever it is possible, should be in some quiet 
part of the house as far removed as possible from the noise of the house- 
hold and street. It should be well lighted and airy, but should be so 
arranged that it can be shaded when necessary, since a partially darkened 
room is more productive of rest and sleep. The light should never strike 
directly into the patient's eyes, and there should be no perceptible draughts. 
Ventilation should be so arranged that no one on entering should be able 
to detect any odor. The temperature should be kept steadily between 
60° and 70° F. No noise or disturbance should be permitted. At no 
time must the lying-in room be made a general meeting place for a large 
circle of relatives and friends. The woman's linen and the bed should 
be kept scrupulously clean. Frequent changes of the napkins and bed 
linen should be made. This can be done readily, without disturbing the 
patient, by making use of draw sheets. 

After-pains. In primipara, as has been said, the after-pains are rarely 
severe enough to demand interference. In multipara, on the other hand, 
they may be very annoying and may seriously discommode the patient, 
interfering with sleep and rendering her miserable. Under such circum- 
stances some treatment must be instituted. The physician should never 
consider any discomfort of his patient as too trivial for his serious atten- 
tion, and although at times he may not think it wise to have recourse to 
drugs for her relief, he will not hesitate to employ them whenever the 
situation demands it. Opium or its alkaloid, morphine, relieves pains 
more effectually than any other drug in the Pharmacopoeia, but is not 
always well tolerated. Chloral alone, even in comparatively large doses 
of 15 or 30 grains, is not very efficacious in relieving pain, although its 
effect is quieting. Some such combination as the following generally 
acts very well : 

Morphinse sulphatis gr. %-% 

Chloral hydrate gr. 10-20 

Bromides are practically worthless against acute pain. They act slowly 
and very feebly. Antipyrine, antifebrine or acetanilid, and phenacetin 
have considerable analgesic action and are occasionally of service. Their 
use should, however, in no case be prolonged, as they are all depressants 
and are said to interfere with involution. Should opium be given it is 
necessary to keep its constipating action in mind and be governed accord- 
ingly. 

Care of the Genitalia. If the labor has been normal and no instruments 
have been used, and no incautious or too frequent vaginal examinations 
have been made, it is safe to assume that the condition of the genitalia 
is physiological, and consequently demands only rigid asepsis to keep it so. 
No vaginal douches are necessary after the completion of the third stage. 
The vulva should be washed off with a stream of sterilized water, its 
action being aided by gentle friction with sterilized fingers or pledgets of 
sterilized cotton held in the forceps, and should then be protected by a 



262 PHYSIOLOGY OF THE PUEBPEBIU31. 

generous dressing of sterilized cotton or gauze. The dressings should 
be changed every hour or two for the first six or eight hours, and during 
the next day every three hours. After this they should be changed three 
or more times daily, according to the amount of soiling. When the dress- 
ings are removed the external genitals should be cleansed of lochia, and 
should then be washed with an antiseptic solution, which in turn should 
be removed with sterilized water. For this purpose under ordinary cir- 
cumstances a saturated solution of boric acid acts best. A 1 to 2000 or 
3000 solution of bichloride might be used, provided one could be sure 
that none of it was allowed to enter the vagina. In view of the fact that 
considerable danger of mercurial poisoning exists, it is better to make use 
of some less toxic antiseptic. A 2 per cent, or a 1 per cent, solution of 
creolin may be employed, but the odor may render its use disagreeable 
to the patient. Should the discharge become fetid, antiseptic douches 
may be called for. Bichloride of mercury and carbolic acid are dangerous 
in the condition in which the vagina and uterus are at this time, but may 
be employed with caution in weak solutions and when carefully controlled 
by the physician. A 1 per cent, solution of lysol, a 2 per cent, solution 
of creolin, hydrogen peroxide in full strength, diluted chlorine water, and 
permanganate of potash in weak solutions have their advocates. Should 
the woman show evidences of infection the case ceases to be physiological 
and becomes pathological. The proper course to be pursued under such 
circumstances will be found in the section on the Pathology of the Puer- 
perium. 

Nursing the Child. Four or six hours after labor, after the mother has 
been refreshed by a good sleep, the child may be put to the breast for a 
few minutes, and then for two or three days, until the secretion of milk 
is established, at intervals of four hours, after which it should be nursed 
every two hours from 6 a.m. to 10 p.m. In this way the child receives 
nourishment nine times in the twenty-four hours, and the mother can 
obtain seven hours or more of uninterrupted sleep. Occasionally one 
nursing at night is necessary. Without regularity in nursing it is hardly 
possible for either mother or child to do well, and many cases of severe 
debility and anaemia in nursing women are due mainly to over-frequency 
in nursing, while the stomach of the child, from want of rest and im- 
proper quality of the milk, is also seriously disturbed. The nipples should 
be gently cleansed after and before each nursing w T ith a saturated solution 
of boric acid, and should then be dried by patting with some soft absorb- 
ent material. Ko rubbing should be employed. Should the nipples tend 
to become sore or cracked, inunction with a little cacao-butter, after each 
nursing and cleansing, may do valuable service by protecting them from 
the air and by softening and rendering the skin more pliable. The mother 
may, perhaps, be unwilling to suckle the child, but when no contraindi- 
cation exists she should be persuaded to do so for her own sake and for 
the child's welfare. The act of suckling promotes involution in the geni- 
talia through reflex nervous action, and thus the mother is benefited. For 
the infant no food is so suitable as its mother's milk, and thus the child 
is benefited. There are, however, certain conditions in which nursing 
the infant may be impossible or inadvisable. In cases in which the 
mother's health is very feeble lactation might be too serious a drain upon 
her. Under such circumstances it will be better for the infant, too, to pro- 



THE PUERPERAL STATE. 263 

hibit suckling, as the mother's milk will almost certainly be defective in 
quality or quantity, and probably in both. A tuberculous mother, even 
when comparatively strong, should not suckle her child, for fear that she 
might infect the infant. This same rule applies also to cases in which 
the woman has contracted syphilis late in pregnancy, since it is just pos- 
sible that the child may not be syphilitic. If, however, the disease was 
inoculated previous to or at the time of conception the child should be 
suckled by its mother, unless other contraindications exist. It is not 
right to subject a non-syphilitic wet-nurse to the risk of infection by 
allowing her to suckle the infant of a syphilitic mother, even should all 
signs of syphilis in the child be lacking. The condition of the breasts 
may contraindicate nursing the child; inversion of the nipples, cracked 
nipples, mastitis, or defective secretion may render suckling impossible 
or inadvisable. Defect in the quality or quantity of the breast-milk will 
quickly make itself apparent by the fact that the child does not thrive 
or gain in weight as it should, even if it shows no signs of serious diges- 
tive disturbance. Moderate "over-feeding" of the mother, combined 
with general tonic and supporting treatment and proper hygienic measures, 
will often rectify this faulty condition. It is. of course, necessary to see 
that the over-feeding does not go far enough to injure the woman's diges- 
tion. The exhibition of drugs, of which there is so long a list under the 
heading of galactagogues, rarely, if ever, does any good. In many cases 
the use of them undoubtedly does harm. Strychnine, iron, and quinine 
in tonic doses are frequently beneficial. It is well to order a certain 
amount of milk at intervals during the day; if taken between meals it 
often agrees better. Malt liquors or extract of malt in moderate doses suits 
some patients. Somatose is believed to be useful. Thyroid extract, gr. j, 
three to five times daily, is said to improve the quantity and the quality 
of the milk. Inversion or retraction of the nipples should, as far as pos- 
sible, have been rectified during the later months of pregnancy. Cracked 
or fissured nipples should be kept scrupulously clean, washed frequently 
with a saturated solution of boric acid, and anointed with cacao-butter 
over which a protective film of the compound tincture of benzoin may 
be applied. A well-fitting nipple-shield is often a great comfort when 
the act of suckling irritates the nipples. In the more severe cases the 
breasts may be drawn by means of a breast-pump and the milk given to 
the child with a spoon or medicine-dropper. Mastitis or mammary abscess 
generally renders the milk unfit food for the infant. Should the breasts 
become painful from over-distention, or should their increased weight 
produce irritation or disagreeable sensations, a compressing or supporting 
bandage may be applied. A w r ide roller-bandage properly applied will 
answer the purpose as well as a specially made breast-binder when the 
latter cannot be procured. Saline cathartics and moderation in the use of 
liquids will aid in diminishing over-distention from profuse secretion. 
Where the child is puny and does not draw enough milk to relieve the 
gland, the breast-pump may be made use of. 

When for any reason it is proper that lactation be brought to an end 
during the puerperium, the application of a proper bandage to the breasts 
and moderation in the use of liquids generally answer every purpose. 
The woman will probably experience some pain in the breasts for several 
days, but this under ordinary circumstances soon subsides and the glands 



264 PHYSIOLOGY OF THE PUERPERIU3L 

undergo involution. Occasionally it may be necessary to give saline 
cathartics. Atropine and iodide of potassium are strongly recommended 
by various authors. Of the latter 5 to 15 grains may be given in water, 
carbonated water, or milk three times a day. Hirt prefers to give this 
drug in hot milk. The syrup of sarsaparilla, in which it is so frequently 
given, adds in no way to its efficacy, and the combination makes a nause- 
ous mixture, which, strange to say, however, is not disagreeable to many 
patients. 

The Visits of the Physician. The physician after the completion of 
labor should always remain within call until the uterus has firmly con- 
tracted and all immediate danger of hemorrhage has passed. He should 
see that the patient is as comfortable as possible, and so order arrange- 
ments that she will get the necessary quiet and refreshing sleep. The 
child's condition should have been examined into, and any defects in 
formation should have been noted. The umbilical cord should be 
inspected to make sure that it is in order and that the ligature has not 
slipped. Just before leaving the physician should give clear and distinct 
orders to the nurse in charge concerning the management of the woman 
and child. These may be put in writing if thought advisable. A visit 
should be made within twelve hours after labor, and at that time both 
mother and child should be examined carefully to see that all is going 
well. The physician himself should note the temperature, pulse, and 
respiration, keeping in mind the ease with which injurious distention of 
the bladder can occur and the fact that the passing of urine is often 
reported with a too full bladder and may simply mean an overflow (enu- 
resis paradoxa). The state of the skin, the digestive apparatus, the 
amount and character of the food, the condition of the uterus and the 
lochia, must all be inquired into. The woman must not be allowed to 
become constipated. After the third day she should have a daily bowel 
passage. The condition and welfare of the child must not be forgotten. 
Inquiries must be made as to whether it has been fed or suckled, whether 
it is thriving and gaining weight or not, and about the conditions of its 
various functions. The nurse should be directed to keep for the reference 
of the physician a record of temperature, pulse, and respiration, of the 
bowel passages of both mother and child, and of the number of feedings 
of the child. Anything else which she may deem of importance for the 
treatment of the case should be duly reported. Temperature, pulse, and 
respiration should be taken three times a day for the first week; after 
that twice a day suffices. For the first week the physician should make 
a daily visit, after which time, providing the nurse be competent to care 
for the case properly, it will be sufficient to see the patient every second 
or third day. The patient should not be allowed to get up until the 
change is sanctioned by express order of the physician, and she must 
continue under his observation until convalescence is fully established. 

Tardy Involution. AVhen the progress of involution is abnormally slow 
it may be promoted by the use of friction, faradism, or small doses of 
ergot. Hot vaginal douching is useful, but this is a matter which can 
seldom be trusted to the nurse. 

Friction is applied to the uterus by the nurse in the same manner as 
in the third stage of labor. The hand, laid flat on the abdomen, moves 
the abdominal wall with it in a circular direction over the anterior surface 



THE PUERPERAL STATE. 265 

of the uterus. The treatment is continued for ten or fifteen minutes 
twice daily. 

Faradism may be applied through the uterus from side to side, the 
electrodes resting on the abdomen, or one on the abdomen over the uterus, 
and the other over the upper sacral region. The current need not be 
strong enough to cause pain. 

Ergot in doses of ten or twenty minims three times daily is frequently 
of service. 

A hot vaginal injection at a temperature of 48.8° C, 120° F. and re- 
peated twice daily is effective. Douches, however, should, as a rale, be 
administered only by the physician and with extreme aseptic precautions. 

A frequent cause of tardy involution, and which may pass unsuspected, 
is a mild infection of the endometrium. In such cases curetting is 
generally required. Curetting on this indication alone is seldom ad- 
visable earlier than the third or fourth week of the puerperium. 

Displacement of the Uterus. The uterus sometimes becomes retroverted 
or retroflexed in the latter part of the puerperal month. This is most 
frequently the case in subinvolution, and particularly when retrodisplace- 
ment had existed before pregnancy. Evidence of the malposition will 
usually be afforded by pelvic tenesmus, by pain in the sacral region, and 
by return of the bloody flow. These symptoms are most marked on 
getting up. If on vaginal examination the diagnosis is confirmed, the 
uterus should immediately be replaced manually and supported by a suit- 
able hard-rubber pessary. The pessary must be worn for two or three 
months. By the timely adoption of this treatment a permanent retro- 
version may almost invariably be prevented. 

Pelvic Examination. It should be a routine practice to make a bimanual 
examination of the pelvic organs in the third or fourth week of the puer- 
perium. The object is to determine the presence or absence of injuries of 
the vagina or cervix, the degree of uterine involution, and the possible 
existence of retrodisplacement of the uterus or other abnormal conditions. 

The Diagnosis of the Puerperal State. 

It is sometimes important for medico-legal or other reasons to deter- 
mine whether or not a woman has been recently pregnant, or whether an 
abortion or labor at full term has lately taken place. In such cases the 
patient herself may be dead or, if living, may for various reasons deny 
absolutely the imputation of pregnancy, so that it will be left to the physi- 
cian to determine from objective signs the true condition of affairs. Since 
the decision may involve serious consequences to one person or more, it 
is especially important not only that the report of the physician should 
be accurate, but that he may be able to bring forward proof which in the 
eyes of skilled witnesses may be considered irrefutable. 

The evidences of a recent delivery may be divided into three classes : 
(1) positive, (2) probable, and (3) uncertain. 

The Positive Signs of the puerperal state are derived from the ovum, 
and are only to be recognized by means of the microscope. The demon- 
stration of placental tissue, especially chorionic villi, in a scraping or in 
a section taken from the uterus, is proof positive that the woman has 
been pregnant within a reasonably recent period. 



266 PHYSIOLOGY OF THE PTJERPERIUM. 

The Probable Signs are numerous. The finding under the microscope 
of the so-called decidual cells, the much-enlarged cells of the uterine 
mucosa or decidua, is not absolutely conclusive, since very similar cells 
are found in certain cases of endometritis. Nevertheless the occurrence 
of these large cells, when found in conjunction with other probable signs, 
affords strongly presumptive evidence of a pregnancy. The same may 
be said of the abdominal strise or lineae albicantes, the contused condition 
of the genitalia, the presence of secretions resembling the lochia, the 
dilated smooth vagina, the soft and lacerated cervix, the enlarged uterus, 
and the swollen breasts with their well-marked areola? and their secretion 
of colostrum or milk. These signs taken singly are not positive, since 
the occurrence of any one alone, or of several of them together, may be 
due to conditions other than pregnancy. The enlarged uterus, the soft- 
ened and more or less lacerated cervix, the abdominal striae, and at times 
even the milk-secreting breasts may ali have had their origin in the pre- 
vious presence and delivery of a large submucous uterine fibroid. It is 
only when a number of them are present at one and the same time that 
the proof of a preceding pregnancy may be said to be established beyond 
reasonable doubt. 

The Uncertain Signs include the relaxed wrinkled condition of the 
abdominal walls, venous varices of the lower extremities, prof nse sweats, 
and other less important symptoms. Such conditions are, of course, met 
with also in men as well as in women who are not pregnant. The 
relaxed, withered appearance of the abdominal walls may be due to the 
absorption or rapid disappearance of a large amount of fluid from a pre- 
vious ascites or a large ovarian cyst. Mottled areas resembling the true 
stride albicantes occur in people who have previously been stout and have 
subsequently lost flesh, and are due, as in the puerperal state, to the 
removal of 'the distention. Signs of this class, therefore, can only be 
regarded as affording confirmatory evidence of a condition indicated by 
those of the other categories. As regards the time that has elapsed since 
delivery, the condition of the lochia, of the vaginal wounds and the 
breast function must be taken into consideration. It must be remem- 
bered that placental and chorionic villi may be found in the uterus 
months after delivery has taken place. Our decision, therefore, on this 
point can never be more than approximate. 



CHAPTER XI 



THE NEW-BORN CHILD AND ITS MANAGEMENT. 



Fig. 209. 



Anatomy and Physiology. 

Befoee considering the management of the new-born infant, it may 
be well to recall some of the more important points in the anatomy of 
early infancy. 

It may be stated in general that the thoracic and abdominal viscera of 
the infant are relatively more highly developed than the brain and gen- 
erative apparatus. The bones are soft and flexible, from the excess of 
animal matter and deficiency of calcium phosphate. The muscular struc- 
tures are poorly developed, while the circulatory and lymphatic systems 
are relatively large. 

The Cranium. The cranial vault at birth is more or less plastic, owing 
to the fact that its bones are not fully ossified nor firmly united. The 
base of the skull is more unyielding than the frontal and parietal por- 
tions. The posterior fontanelle is usually nearly closed at birth, while 
the anterior generally remains widely open. (Fig. 209.) The closure 
of the anterior fontanelle at birth, or soon 
after, is abnormal, and may indicate that the 
brain is abnormally small. When it is ab- 
normally large it indicates a lack of develop- 
ment of the bones. 

As the jaw is rudimentary, and the teeth 
absent, the facial part of the skull is rela- 
tively small. 

The Spinal Column is straight at birth, but 
marked by great flexibility. The usual adult 
curvatures in the dorsal and sacro-coccygeal 
regions are but little developed in early in- 
fancy. The development and co-ordinating 
powers of the spinal muscles are feeble. It 
is usually several weeks before the infant can 
hold its head erect. 

The Nervous System is imperfectly devel- 
oped at birth. Although the brain is large, it is soft and presents no 
sharp distinction between the gray and white matter. The spinal cord 
is relatively in a higher stage of growth than the brain, especially the 
anterior horns. The posterior and sensory portions of the cord are more 
immature. This explains the fact that motor manifestations are so active 
at this time, as sensory irritations and disturbances are quickly reflected 
into the predominant motor area. The rapid and irregular character of 
the muscular movements is evidence of this physiological fact. No act 
of volition takes place in the new-born, all movements at this period 
being automatic or reflex. Reflexes can be obtained after birth not only 

( "267 ) 




Anterior and posterior fontanelles. 



268 PHYSIOLOGY OF THE PTJEBPERIUM. 

from the cutaneous nerves of the surface, but from the nerves of special 
sense — the optic, olfactory, and auditory. 

Special Senses. The pupils of the eye may be unequal in size, but they 
react to light. The perception of light by the new-born is, however, 
imperfect, and the sense of sight, other than the ability to distinguish 
light from darkness, is not developed. Hearing is also imperfect, as the 
cavity of the tympanum is apt to be filled with fluid and the tympanic 
membrane is placed in a horizontal position. The senses of taste and 
smell are feebly developed at this time. The size of the peripheral nerves 
is relatively large, but their function is not active during the first few 
days after birth. 

The Thorax. ■ The thorax is of small size in the new-born, the cir- 
cumference being a little less than that of the head. The cavity is shal- 
low in its antero-posterior diameter, the distance from the vertebral 
column to the manubrium being so small that compression may be 
induced by enlarged lymph-glands. There is a widening out, relatively 
great, toward the base of the cavity. The ribs are soft and elastic, 
being inserted in a rectangular and horizontal direction, which renders 
the respiration almost entirely abdominal. The intercostal muscles are 
thin and they exert little action on the ribs. The first dorsal vertebra is 
on a level with the upper margin of the sternum at birth, but later the 
second dorsal vertebra assumes this position. 

The Lungs. Just before birth the unaerated lungs lie in the posterior 
part of the thorax on either side of the pericardium. Immediately on 
delivery several deep and spasmodic inspirations should quickly inflate 
the lungs, which then assume a pinkish color. For the first few weeks 
the respirations are irregular in character, and tkey vary in frequency 
from 35 to 50 per minute. At times a pause of a few seconds between 
inspiration and expiration may be noted. The active growth and devel- 
opment of the infant results in the production of double the amount of 
carbon dioxide in proportion to its weight that is normal in later life. 
Hence the importance and stress of work that falls upon the lungs, which 
are smaller in proportion to the weight of the body than in the adult. 
The rapidity and tumultuous character of the respiration common in 
early infancy are thus explained. 

The Heart. The heart in the new-born is relatively wide, from the 
development of the right side, which has been functionally active during 
intra-uterine life. As a consequence, the apex-beat reaches to the mam- 
millary line, and sometimes outside of it. A glance at the changes taking 
place in the circulation at birth will explain certain cardiac anomalies of 
early infancy. The blood from the placenta, after passing through the 
liver, with the exception of a small portion passing through the ductus 
venosus, joins with the blood returned from the lower extremities by the 
inferior vena cava. This is delivered into the right auricle, and passes 
through an opening, the foramen ovale, guided by the Eustachian valve, 
into the left auricle. It passes directly from the left auricle into the left 
ventricle, and thence into the aorta. The blood in the aorta is distributed 
principally to the head and arms, although a small portion may be car- 
ried by the descending aorta to the lower extremities. This explains the 
unequal development of the upper and lower extremities of the foetus. 
The return circulation from the head and upper extremities is collected 



THE NEW-BORN CHILD AND ITS MANAGEMENT. 269 

by the superior vena cava, which empties into the right auricle, mixing 
with a little blood from the inferior vena cava. It passes over the 
Eustachian valve from the right auricle into the right ventricle, and 
thence into the pulmonary artery. Very little blood passes from the 
pulmonary artery to the lungs in the foetus, as these organs are solid and 
nearly impervious; the great mass of this blood passes through the canal 
of the ductus arteriosus into the descending aorta, where some is distrib- 
uted to the lower extremities and abdominal viscera, but most of it is 
carried to the placenta by means of the umbilical arteries. The rela- 
tively large development of the head and upper extremities at birth is 
explained by the fact that the fresh blood from the placenta passes first 
to these parts, as explained above, while the blood reaching the lower 
extremities by the descending aorta has already circulated through the 
upper part of the body. At birth, with the interruption of the placental 
circulation, the lungs should immediately inflate and draw off a large 
supply of blood through the pulmonary arteries. The foramen ovale 
gradually closes, and the opening should be completely occluded by the 
tenth day. At times this process is not complete, and a small valvular 
opening remains between the auricles. As soon as respiration begins, 
the ductus arteriosus commences to contract, and the occlusion should be 
complete from the fourth to the tenth day. The size of the heart in the 
new-born is large as compared with the rest of the body. According to 
Gray, this ratio is as 1 to 120 at birth, while in the adult the average 
is about 1 to 160. The arteries are also relatively wide in comparison 
with those of the adult, and the arterial pressure is small in young infants. 
The heart acts quickly and somewhat irregularly in the new-born, the 
pulse-rate varying from 125 to 140 or 150. 

The Blood. Upon ligation of the umbilical cord and the cessation of 
the placental circulation, important changes follow, not only in the 
infant's circulation but also in the blood itself. 

These changes appear to be first of a degenerative nature, and they are 
consequent upon a more perfect oxygenation of the blood. Immediately 
after birth the red corpuscles number six or seven millions per cubic 
centimetre, while by the fourth or fifth day the number has dropped to 
four or five millions. The size of the red corpuscles at birth is likewise 
variable, and the white corpuscles are present in much greater proportion 
than in the blood of the adult. The amount of blood in the new-born 
is less in proportion to the body-weight than in older subjects. The 
quantity of blood immediately after birth will vary somewhat according 
to the length of time during which connection with the placenta is main- 
tained. Just after birth, there is comparatively little fibrin in the blood, 
hence a certain slowness of coagulation. Cephalhsematomata are slow in 
solidifying, and meningeal apoplexies are apt to spread over the surface 
of the brain as a result of this condition of the blood. Its specific gravity 
is also somewhat lower than in later years. 

The Digestive Organs. A peculiarity of the mucous membrane of the 
mouth in the new-born consists in its thinness and the frequent exist- 
ence of minute patches of epithelium on the median line of the palate, 
the so-called " epithelial pearls." 

The Stomach. The stomach is small, with more of a vertical than a 
horizontal inclination, the fundus being absent. It is little more than a 



270 PHYSIOLOGY OF THE PUERPERIUM. 

simple dilatation of the intestinal tube, and will hold without distention 
only about an ounce of fluid. Vomiting easily ensues by a sort of regur- 
gitation, without nausea, when overfilling takes place, by simple contrac- 
tion of the walls of the tube. 

The Intestines. The small intestine is not uniform in its length at 
birth, but measures, on an average, a little more than nine feet. The 
large intestine measures not quite two feet, and is distinguished in the 
new-born by the greater relative length of the lower part of the colon. 

The Liver. The liver at birth is of relatively large size, being greater 
in bulk than both lungs, and containing much blood. The large size and 
importance of the liver in foetal life will be understood by considering it 
a sort of intermediary organ between the placenta and the general circu- 
lation, as far as the re-oxygenated blood is concerned. At birth the com- 
munication between the placenta and the liver and portal vein, by means 
of the umbilical vein, is severed by cutting the cord. The lungs at once 
inflate and assume the respiratory function. The umbilical vein begins 
to shrink, and is completely obliterated between the second and fifth 
days of life. It is finally reduced to the fibrous cord known as the round 
ligament of the liver. The ductus venosus is usually obliterated within 
a few days after birth. Although the liver has now lost its preponder- 
ating importance in the economy, it still remains relatively larger and 
heavier than in later life. The diminution of the organ is due to its 
altered blood-supply, and is especially marked in the left lobe. The loss 
of weight that begins at birth continues from infancy to old age. 

The digestive juices are imperfectly secreted in the new-born. Saliva 
is present in some degree with slight proteolytic power; the gastric juice 
is fairly active, but the pancreatic secretion does not attain physiological 
potency for several months. The intestinal glands are likewise in a low 
stage of development. The bile is poor in cholesterin, lecithin, fat, the 
special bile acids, and in inorganic salts. It is, hence, not difficult to 
understand the feeble digestive powers of early infancy, and the necessity 
for the greatest care in the administration of nutriment. 

The Urinary Organs. The pelvis is shallow; its inclination is exagger- 
ated, and its capacity is small. The bladder is largely an abdominal 
organ. 

The Kidneys. The kidneys are embedded in loose, fatty tissue, low 
down in the abdominal cavity, covered only in front and on their exter- 
nal borders by peritoneum. They are relatively of large size, and are 
distinctly lobulated. Crystals of uric acid often form in the calyces and 
in the pyramidal portions of the kidney during the first few days of life, 
and may produce considerable disturbance by their presence. The supra- 
renal capsules are also of large size, sometimes completely covering the 
kidneys. 

The Bladder. The bladder when distended is oval or egg-shaped in 
form, without a marked fundus, and it lies principally in the abdomen. 
The muscular wall is relatively very thick and dense, so that in female 
infants the bladder may be mistaken for the uterus on autopsy. In the 
female the urethra is placed along the anterior wall of the vagina, and 
its meatus appears almost as large as the orifice of the vagina. Confu- 
sion is sometimes encountered in passing a catheter unless this fact is 
borne in mind. Urination may take place at birth or a few hours after, 



THE NEW-BORN CHILD AND ITS MANAGEMENT. 271 

when the fluid is clear and light colored, or it may be delayed for twenty- 
four hours, when its appearance is apt to be deep yellow aud turbid. 
Sometimes when the urine is surcharged with uric acid and the urates, 
yellowish or red deposits are left upon the napkin, which the attendant 
may mistake for blood. The daily amount of urine is scanty during 
the first three days, or before the free secretion of milk; it increases very 
rapidlv during the next few days. Its average specific gravity is from 
1005 to 1010. 

The Skin. The skin of the new-born infant is soft and red, and covered 
with very fine hairs called lanugo, which are shed during the first few 
^weeks. The sebaceous are more active than the perspiratory glands. 
Immediately after birth, the whole surface of the body is covered with 
sebum, with which are mixed epithelial cells and lanugo. 

The Lymphatics. The lymphatics are abundant and large in size in 
young infants, having a very free communication with all parts of the 
body. 

Growth. The infant loses in weight during the first two or three days 
following birth, but after this there should be a steady increase in growth. 
According to Dr. Money, after the fourth day the body gains in weight 
at the rate of three ounces for the second week, four ounces for the third, 
five ounces for the fourth, and during the second month an ounce a day 
is about the proper rate of increase. The average weight at birth, of 
well-developed infants, varies from seven to eight pounds. The muscles, 
which are feebly developed in the new-born child, increase rapidly in 
size and strength. The average length of the male infant at birth is 
about 50 centimetres, and of the female, about 49 centimetres. 

MANAGEMENT. 

Respiration. The first duty of the attendant, after the delivery, is to 
see that respiration is established. The mouth should quickly be cleansed 
of mucus or blood, and the infant placed on its back or right side. If 
it does not breathe at once, respiratory efforts may be provoked by such 
simple measures as blowing on its face, a few smart taps with the hand 
upon the buttocks, or sprinkling with cold water. If the child draws 
three breaths during the first minute, it may usually be left to itself. 
Should it still fail to breathe, examination is made to see if the heart is 
pulsating. If it is, the cord is severed and artificial respiration main- 
tained as long as the cardiac pulsations can be felt or until regular spon- 
taneous respirations are established. For the methods of performing 
artificial respiration, the reader is referred to the Treatment of Asphyxia 
of the Xew-born. 

Ligation of the Cord. As soon as respiration is established, the cord, 
in the absence of navel cord hernia, is firmly ligated at a distance of 
about one-half to one inch from the cutaneous line. The ligature should 
be aseptic, strong, and of sufficient size to prevent cutting into the walls 
of the vessels. The cord is then cut with clean scissors, about one-half 
inch from the ligature, on the placental side. It is unnecessarv to apply 
two ligatures and cut the cord between them, as is sometimes recom- 
mended, except in case of twin births. By allowing the blood to escape 
from the placenta its volume is reduced and its delivery rendered 
easier. If, however, the bleeding from the cut end of the cord should 



272 PHYSIOLOGY OF THE PUERPERIUM. 

be profuse, and continue for a considerable time, it is best to tie .it. 
When the cord is unusually large, a part of the gelatinous portion may 
be stripped away, lest it retard desiccation, and by shrinkage loosen the 
ligature. If the first ligature does not entirely arrest the oozing of 
blood from the cut end of the cord, another should be applied nearer 
the body. 

The Bath. The child is now wrapped in a previously warmed blanket 
or flannel. If much time has been consumed in establishing respiration, 
it may be well to place it in a basin of warm water for a few minutes, to 
warm its extremities and stimulate its circulation, before wrapping in 
the blanket. The water should not be warmer than 100° F. Care is 
necessary to avoid too much exposure of the new-born infant during the 
first few hours of its life. If its circulation is feeble, or if it seems 
weak or chilly, the first bath should be postponed, and its body heat be 
conserved by wrapping in cotton, with a shawl or blanket outside of this. 
Usually the cleansing may be proceeded with as quickly as possible. 
The bathing should be done in a warm room. During the process the 
infant should be protected from exposure. The sebum can easily be re- 
moved by covering the skin with a bland oil, such as sweet oil, lard, or 
vaseline, applied Avith the hand. Gentle friction maybe necessary when 
the cheesy mass is tenacious. When the whole body has been freely and 
systematically anointed, the surface may be cleansed with soap and water; 
finally the infant is immersed in water at a temperature of about 95° F. 
It is then enveloped in a large towel and dried. Great care should be 
observed in thoroughly cleansing the eyes and mouth. For this purpose 
a saturated solution of boric acid or borax in water may be used. The 
eyes are to be thoroughly cleansed of all vaginal secretion by allowing 
the solution to drop from absorbent cotton that has been saturated with 
it. After this irrigation, small masses of matter still adhering may be 
removed by mopping the lids with the cotton. A careless and free use 
of soap is sometimes responsible for irritated or inflamed eyes. The 
mouth may next be gently washed out with a soft rag wet with a similar 
solution. 

Care of the Cord. The stump of the cord, after being cleansed and 
dried, should have an extra ligature applied if required for safety, and 
then be wrapped in absorbent cotton or antiseptic gauze. Mummifica- 
tion of the stump is the chief object of the navel dressing. The appli- 
cation of oil or powder to the stump is to be omitted, since these agents 
tend to prevent a rapid desiccation. The time-honored dressing of linen 
rag with a hole in the centre, through which the stump protrudes, is 
permissible only when the linen cloth has been recently boiled. The 
stump when dressed is laid flat on the abdomen with the cut surface 
directed to the left, and kept in place by the ordinary belly-band. 
The cord usually separates in from four to seven days. When this 
occurs a small superficial ulcer is left that should soon heal. This also 
is to be kept dry, and may be dusted with boric acid. 

Examination of Child. Before the bath, a careful inspection of all parts 
of the body should be made to detect possible malformations. This 
should include the head, mouth, neck, chest, abdomen, spine, anus, and 
genital organs. A rectal injection may be employed to make sure that 
the rectum is pervious. 



THE NEW-BOBS CHILD AND ITS MANAGEMENT. 273 

The Clothing. After the bath the child is dressed. The belly-band 
may consist of light merino in summer and soft flannel in winter, reach- 
ing from the axilla? to the hips. It should not be applied too tightly 
for fear of embarrassing the movements of respiration. No general rule 
need be given in respect to the exact amount and character of the cloth- 
ing. Two things, however, are essential : It should be sufficiently warm, 
as tested by feeling the child's hands and feet, and it must be loose 
enough to allow free play for movements of the hands and feet, and 
for respiration. During sleep the sides of the head and the neck and 
shoulders may be covered with a light shawl. It is, however, un- 
necessary, if not harmful, to cover the face so as to interfere with a proper 
supply of fresh air. 

Maternal Nursing. After the mother has rested for six or seven hours, 
the infant may be applied to both breasts. This helps to establish the 
habit of suckling, and stimulates the mammary glands and the uterine 
contractions in the mother. No other food should be permitted except by 
special direction of the medical attendant. It should be remembered that 
the new-born infant is unprepared for digestion, and feeding is likely to 
do harm. 

If there are reasons why the child should not be put to the breast at 
this early period, a teaspoonful of warm sterile water may be given at 
intervals of an hour or two if it is restless. The administration of 
water as a routine practice is useful for flushing the kidneys. 

The mother, as a rule, should nurse her own infant. Natural nursing, 
for the first nine months, is so essential to the child's well being, especially 
in large cities, that nothing short of necessity should prevent it. Rarely, 
malformations of the nipples, depressed or retracted nipples, or exten- 
sive fissures may make nursing difficult or impossible. 

To obtain the best results the greatest possible regularity in nursing 
must be observed. The child should not, as a rule, be allowed to nurse 
oftener than once in two hours during the day, and in four to six hours 
during the night. In its own interest and that of its mother, the child 
should not sleep in the bed with the mother, but in a crib. It is im- 
portant for the mother's health, as well as for the quality of her milk, 
that she have six or seven consecutive hours of sleep at night. 

One of the commonest causes of trouble comes from nursing the infant 
whenever it cries, for the purpose of quieting it. This is one of the most 
frequent sources of acute and of chronic infantile indigestion. Violent 
emotional paroxysms on the part of a nursing mother ma}^ so modify 
the milk as to produce acute indigestion or severe nervous disturbance 
in the infant. Convulsions, acute diarrhoea, collapse, and even death, 
have been known to result from this cause. Colic and indigestion in 
the infant are sometimes due to digestive derangements of the mother. 

The infant should suckle the breast for about fifteen minutes at each 
nursing, and then fall asleep. If it is unsatisfied and fretful, after nursing 
for that length of time, there is probably insufficient milk in the breast 
or indigestion in the child. The breast milk may fail either in quantity 
or quality. If two little is secreted, stimulation of the gland and a 
generous diet are indicated. The most natural stimulation comes from 
the application of the infant at comparatively frequent intervals ; a long 

is 



274 PHYSIOLOGY OF THE PUEBPERIUJI. 

interval is sometimes allowed with the mistaken idea that rest may enable 
the gland better to fulfil its functions. 

A generous supply of nourishing and easily digested food is indicated. 
Oatmeal gruel, thin and well cooked, has a reputation for promoting the 
milk secretion, which seems to have some foundation in fact, although 
extended experiments seem to indicate that the chemical composition of 
the milk is but slightly affected by the character of the food provided a 
liberal supply is taken. A diet rich in preteid matters usually increases 
the per cent, of fat in the milk, but not the proteids. The liberal use 
of cows' milk has a like effect. Malt liquor, such as ale or porter, by 
stimulating the appetite, may indirectly aid the production of milk. 
The digestion and assimilation of the nursing mother often suifer for 
want of proper exercise, with the effect of impairing the quality and 
lessening the quantity of milk. Regular exercise in the open air must 
be advised as soon as circumstances permit. 

It must not be forgotten that the mammary gland may act as an excre- 
tory as well as a secretory organ. This is especially true at the beginning 
of the lactation period, when great care must be exercised in giving 
drugs that may be excreted in the milk and affect the infant. Alcohol, 
opium, and belladonna are known to be thus eliminated in amounts 
sufficient to produce appreciable effects upon the infant. 

Contraindications to Maternal Nursing. Most mothers prefer to nurse 
their offspring, and the physician should encourage adherence to the 
natural method of feeding in the absence of a definite contraindication. 
The following are the conditions which most frequently prevent or forbid 
nursing : 

1. Depressed, or otherwise deformed nipples; 

2. Diseases of the nervous system in general; 

3. Epilepsy, when the seizures come oftener than twice a year; 

4. Hysteria, especially after a pronounced hysterical disturbance; 

5. Certain constitutional diseases, such as tuberculosis or syphilis; 

6. Chronic diseases of the skin, such as eczema, prurigo, psoriasis, etc. ; 

7. Caries and chronic joint diseases; 

8. Chronic rheumatism; 

9. Advanced cardiac or renal disease; 

10. Puerperal fever continuing more than two or three days; 

11. Metrorrhagia when prolonged, since it has a very deleterious effect 
upon the composition of the milk. The appearance of the regular men- 
strual flow is not a contraindication to nursing unless the child shows 
signs of disturbance at the epochs; 

12. Pronounced anaemia not easily corrected by treatment; 

13. Abnormal milk, when it disturbs the digestion of the infant, and 
when it cannot be corrected by changes in the mother's diet or faulty 
habits. 

Mother's Milk is a secretion of the mammary glands, consisting of an 
emulsion of fat suspended in a clear transparent liquid, in which sugar, 
caseinogen, lactalbumin, certain extractive matters and inorganic salts 
are dissolved. A good normal mother's milk has a bluish- white appear- 
ance, is more tranpsarent than cow's milk, and has a sweeter taste than 
the latter. It is neutral or slightly alkaline, frequently amphoteric in 
reaction, and has a specific gravity of 1026 to 1036. AVhen examined 



THE NEW-BORN CHILD AND ITS .MANAGEMENT 



275 



under the microscope, the milk globules will be found to vary greatly in 
size : each is surrounded with a layer of more or less viscid material, which 
prevents them from running together. According to Woll, 1 c.c. contains 
1.6 million globules, from 0.0024 to 0.0045 mm. in diameter. 

Colostrum. The fluid secreted by the mamma? during the first three 
days after the birth of the child is called colostrum. It differs materially 
in composition from the true milk secreted later. It contains more pro- 
teid matters, less fit, and less sugar than milk. The amount of proteid 
varies greatly in different cases, from 2 to 8 or 9 per cent. We may 
take 2 to 3.5 per cent, as a fair average of the proteids during the first 
week of lactation. The proteids of colostrum are made up largely of 
albumin and globulin, instead of caseinogen. The fat of colostrum 
begins at about 2.5 per cent., and rises rapidly to 3.5 per cent. The 
sugar begins at about 5 per cent., and rises rapidly to 6.5 per cent, by 
the end of the second week. 

During the first eight or nine days after parturition, and sometimes 
later, the milk contains characteristic, larger bodies, known as colostrum 
corpuscles. These appear to be composed of masses of protoplasm con- 



FiG. 210. 



Fig. 211. 





Colostrum corpuscles. 



Normal human milk. 



taming fat. The colostrum corpuscles are four to five times as large as 
the fat globules. (Fig. 210.) They may occur in milk at any later 
time during the lactation period, and are then to be regarded as evidence 
of illness in the mother, or of pregnancy. Occasional colostrum cor- 
puscles in the milk have little or no significance, but if present in 
considerable number they are liable to cause digestive derangement in 
the child. 

Normal Human Milk. Normal milk has the appearance seen in Fig. 
211. In taking a sample of milk for microscopic examination, it should 
be drawn after the child has about half emptied the breast, and not at 
the beginning or end of the nursing. The microscope is often of value 
in showing the presence of blood, pus, or other foreign elements, but it 
is of little value as a guide to the richness of the milk, on account of 
the difficulty in securing a sample that represents the average secretion 



276 PHYSIOLOGY OF THE PUERPERIUM. 

of the breast. The centrifuge should be used to separate the cellular 
elements in the microscopical examination of the milk. The length of 
time the milk has remained in the breasts exerts an important influence 
upon the number of globules it contains. The longer the period of 
retention the more watery it becomes, probably from absorption of the 
solid parts. On the other hand, milk that is frequently taken from the 
breast is thicker from being richer in fat. 

Abnormal Mother's Milk. It occasionally happens that an apparently 
healthy mother secretes an abnormal milk that disagrees with the infant 
The constituents most subject to variation are the fat and the proteids. 
Our knowledge of the causes of these variations is, unfortunately, im- 
perfect. Rotch and Adriance find that a diet rich in nitrogenous matter 
tends to increase the fat in the milk, while an abundance of fat in the 
food tends to diminish it. Excess of proteids is usually more troublesome 
than any other abnormality. Rotch also pointed out that an over-liberal 
diet, with little exercise, may increase the proteids in the milk; a less 
generous diet, with abundant out-door exercise, may correct this abnor- 
mality. Marked emotional disturbance frequently increases the proteids 
temporarily and causes colic in the nursling. 

The following table of variations in human milk, from Rotch, is of 
interest in this connection : 

Normal. Poor. Very rich, Bad Milk. 

Normal exercise Starva- Generous diet. Pregnancy, 

and food. tion. Little exercise. disease, etc. 

Fat 4.0 1.50 5.10 0.80 

Proteids 1.2 2.40 3.50 4.50 

Sugar 7.0 4.00 7.50 5.00 

Ash 0.2 0.09 0.25 0.09 

Total solids . . 12.13 7.99 16.35 10.39 

Water 87.87 92.01 83.65 89.61 

100 100 100 100 

When there is reason to believe that the mother's milk is not agreeing 
with her infant, an excess of casein should be suspected, and an analysis 
by a chemist may reveal the fault if it lies in the milk, and point out 
the way to its correction. It is advisable in all such cases to examine 
carefully into the mental and physical habits and characteristics of the 
mother. 

Daily Quantity of Milk Secreted. The daily amount of milk secreted 
by the average mother, and the weight of each feeding and of each con- 
stituent at different periods of lactation, are given in Table I. (page 277), 
from Pfeiffer. The results were obtained by weighing a series of infants 
before and after each nursing, and adding the weights of all the feedings 
for the twenty-four hours. The weights of each constituent were obtained 
by calculation from the known composition of the milk as determined by 
chemical analysis. 

Variations in Quantity and Composition of Human Milk. It will be 
noted that the quantity of milk secreted increases gradually from the 
beginning of lactation until about the tenth week, then remains practi- 
cally stationary until the sixth month, when it increases somewhat, and 
finally decreases. Human milk varies considerably, both in quality and 
quantity, in different individuals, and even in the same individual. 



THE NEW-BORN CHILD AND ITS MANAGEMENT. 



277 



Table I. 



Age of infant. 



1 month. 

1 ., week 

1 " 

2 weeks 

3 " 

4 " 

2 months. 

5- 6 weeks 
7- 8 

3 months. 

9-10 weeks. 
11-12 " 

4 months. 

13-14 weeks 
15-16 " 

5 months. 

17-18 weeks 
19-20 weeks 

6 months. 

21-22 weeks 

7 months. 

25-28 weeks 

8 months. 

29-32 weeks 

9 months. 

33-36 weeks 



Total 
amount in 
grammes. 



104 
254 
334 
449 
550 

749 

864 

926 



974 

996 
996 

1023 

1051 
741 
482 



Number and 
weight of 
each meal. 


Proteids 

in 
grammes. 


Fat 

in 

grammes. 


8 X 13 
7 X 36 
7 X 48 
7 X 68 
7 X 71 


4.40 

8.74 

7.64 

10.27 

12.58 


2.81 

6.86 

12.13 

12.13 

17.86 


7 X 107 
7 X 123 


13.82 
15.83 


22.52 
26.40 


7 X 132 
7 X 128 


17.68 
17.10 


20.43 
20.25 


7 X 138 
7 X 139 


19.53 
19.62 


39.02 
39.23 


7 X 142 
7 X 142 


17.38 
17.42 


52. 36 

52.28 


6 X 167 


15.82 


26.88 


6 X 174 


15.99 


34.77 


6 X 124 


12.15 


28.69 


6 X 88 


7.26 


11.62 



Sugar 

in 

grammes. 



4.69 
11.44 
15. 05 

20. 23 
24.78 

41.47 
45.03 

55.28 
53.50 

59.12 
59.39 



60.00 
60.40 
42.80 
28.94 



because of varying physiological and pathological conditions relating to 
food, nutrition, duration of lactation, length of time the milk remains 
in the breast, exercise, menstrual function, emotions, and nervous affec- 
tions. 

It is, therefore, very difficult to arrive at the normal composition of 
human milk, since these disturbing elements have not been taken into 
account in most of the published analyses. Analyses of human milk by 
different chemists differ so widely that it is difficult as yet to determine the 
typical normal standard. In general, it may be stated that during the 
first week of lactation colostrum is secreted, containing less fat and sugar 
than normal milk, more proteids (the greater part of which is laoto- 
globulin and lactalbumin), and more salts. 

The fat and sugar rapidly increase after the third day till the end of 
the first month; from that time the proportions of these ingredients 
remain constant until about the eleventh month, when they fall off. 
The proteids and salts exist in much larger percentages in colostrum 
than in normal milk, the former containing on an average 2.5 to 3.5 per 
cent, of proteids and 0.4 to 0.5 per cent, of salts. Both these constituents 
gradually diminish until the eleventh month, when they again slightly 
increase. During the first month of lactation, human milk contains 
between 1.5 and 2.5 per cent, of total proteids; during the second about 
2, and in the third about 1.5 per cent. 

The percentage of iron falls off as lactation proceeds, and after the 
eighth or ninth month it becomes decidedly less than normal. The milk 
of the early months of lactation, then, is characterized by a large per- 
centage of proteids and salts, and a small percentage of sugar. That of 
the later months is characterized by a smaller percentage of proteids and 
salts, and a higher percentage of sugar. The smaller proportion of pro- 
teids and of iron in the later months contraindicates prolonged nursing. 
When children are nursed too long (beyond the eleventh month) they 



278 PHYSIOLOGY OF THE PUERPERIUM. 

frequently show symptoms of malnutrition, and often become anaemic 
or rachitic. 

It is of interest to note that the composition of the milk varies greatly, 
according to the time it has remained in the breast. Forster gives the 
following analyses of the first, the middle, and the last portions taken 
from the breast during an ordinary nursing : 

First portion. Second portion. Last portion. 

Amount taken .... 33.1 c.c. 33.1 c.c. 37.3 c.c. 

Water 90.24 per cent. 89.68 per cent. 87.50 per cent. 

Proteids 1.13 " 0.94 " 0.71 

Fat 1.70 " 2.77 " 4.51 

Sugar 5.56 " 5.70 " 5.10 " 

Ash 0.40 " 0.32 " 0.28 

It is evident from the foregoing figures that care must be observed in 
obtaining a sample of milk for analysis, if we wish to secure results that 
are comparable or that will represent the real composition of the secretion. 
The middle portion only should be taken, after the child has nursed one- 
third of its usual time. These analyses also show that in too frequent 
nursing the child gets only " strippings," or over-rich milk, likely to 
disturb digestion. 

Substitute Feeding. 

Wet-nursing. When, after proper effort, the mother is unable to nurse 
her infant, w T et-nursing may be considered. So difficult is it to secure a 
good wet-nurse that the uncertainties of this method are often scarcely 
less than those attending artificial feeding. The expense, too, of sub- 
stitute nursing places it beyond the reach of the masses. 

The moral character and social standing of most women who are will- 
ing to wet-nurse are such that many families shrink from taking them 
into their homes. While the danger of the transmission of syphilis or 
tuberculosis by an apparently healthy nurse has been overestimated, it 
is, nevertheless, a real one, and no woman the subject of either of 
these diseases should be allowed to nurse an infant. There are many 
instances on record in which syphilis has been communicated in this 
way. 

While healthy breast milk is undoubtedly the best food for an in- 
fant, it is equally true that with a proper knowledge of the best modern 
methods of substitute feeding there is now little need of resorting to 
wet-nursing. 

Mixed Feeding. It frequently occurs that the mother is able only to 
partially nurse her baby. In such cases mixed feeding should be resorted 
to — i. e. , the mother should nurse the infant at regular intervals, and the 
nursing should be supplemented by two or more artificial feedings in the 
twenty-four hours. The practice of nursing only at night, which is some- 
times advised, is objectionable. Regularity of nursing is essential to the 
continuance of the secretion. Mixed feeding may sometimes be rendered 
necessary by the transient illness of the mother, or by a temporary 
deficiency occasionally resulting from unassignable causes or from 
nervous or emotional influences. In some instances the secretion may 
be restored by faradization of the breasts or by change of surroundings. 

Artificial or Bottle Feeding. When good breast milk is not available, 



THE NEW-BORN CHILD AND ITS MANAGEMENT 279 

artificial food must be provided, and its preparation must be managed 
with scrupulous care. When it becomes necessary to practise artificial 
feeding from birth, we may, with advantage, use whey made from cows' 
milk lor the first few days. For this purpose the whey should be made 
by warming a pint of best rich whole milk to about 37° C. (98.6° F.), 
adding a teaspoonful of liquid rennet, essence of pepsin, or a junket 
tablet. When curdling has taken place the mixture is vigorously 
stirred until the curd collects into a lump. The whey is strained 
through sterilized cheesecloth, and put on ice until needed. Whey 
made as above, from good, rich milk, will have approximately the fol- 
lowing percentage composition (Monti) : 

Casein. I^eids. Fat - Sugar ' Salts> Water ' 

0.03 0.8 1.0 4.5 0.70 93.0 

About two ounces of this Avhey warmed to blood-heat may be given 
during the first twenty-four hours to an infant of average size. Four 
ounces may be given the second day, and from eight to ten the third. 
The fourth or fifth day a little cream may be added to the whey, and 
a little sugar if desired. 

A substitute food for continued use should fulfil the following require- 
ments : (1) It should correspond in composition, digestibility, tempera- 
ture, reaction, and quantity as nearly as possible, to normal human 
milk. (2) Its preparation should be as simple and uncomplicated as 
possible. (3) It should not be expensive, and should be easily obtain- 
able. The basis of an infant food must be milk, and in this country 
the only easily obtainable animal milk is that of the cow. Great care 
is necessary in selecting the milk. It should be the mixed milk of a 
herd, and not that from a single cow, since the former is more nearly 
of constant quality. It should be as fresh as possible, and clean. 
Milk from grass-fed cows is to be preferred. For use in large cities 
milk that has been bottled at the dairy, and subjected to the least pos- 
sible amount of handling in shipping, is best. 

Difference between Human and Cow's Milk. To understand properly 
the modification of cow's milk for infant feeding it is obviously neces- 
sary to know the differences in composition and properties between it 
and human milk. Some of the more important differences are shown 
in the following table : 

Human milk. Cow's milk. 

Percentage. Average. Percentage. Average. 

Water ..... 83.69 to 90.00 87.09 80.32 to 91.50 87.41 

Solids 9.10 " 16.11 12.46 8.50 " 19.68 12.50 

Fat 1.71 " 7.60 3.90 1.15 " 7.09 3.66 

Sugar 4.11 " 7.80 6.36 3.20 " 5.67 4.50 

Casein 0.18 " 1.98 1.03 1.17 " 7.40 3.04 

Albumin .... 0.39 " 1.35 1.00 0.21 " 1.50 0.53 

Citric acid .... 0.04 " 0.10 0.05 

Unknown extractives . 0.29 " 0.97 0.69 

Ash 0.14 " 0.40 0.27 0.50 " 0.78 0.70 

Calories furnished by 100 c.c. (3.5 ounces) 69.00 67.00 

It will be seen that the range of variation in composition of both milks 
is very considerable. These variations include abnormal or pathological 



280 rHYSJOLOGY OF THE PUERPERIUM. 

conditions, and will largely disappear when the mixed milk of several 
individuals is considered. Mixed cow's milk of good quality will not 
vary much in composition from that given in the column marked "aver- 
age." When the averages of the two milks are compared, we observe 
that human milk is slightly richer in fat, one-third richer in sugar, twice 
richer in albumin, and contains one-third as much casein (precipitable by 
rennet), and a little more thau one-half as much ash as cow's milk. The 
most marked quantitative differences are in the sugar and the proteids. 
The proteids are chiefly casein and albumin, although a small quantity 
of a peculiar globulin is also present. The casein, or that part of the 
proteids which is precipitated in the human stomach by rennin or by 
the gastric acid, is three or more times as great in cow's as in human 
milk. By reason of this, as well as differences in composition of the 
two kinds of casein, the curd of cow's milk is larger in amount, tougher 
in consistence, and less easily digested than that of human milk. Indeed, 
the casein of human milk is only partially precipitable by acids, and in 
some cases imperfectly by rennin. The soluble albumin in human milk 
is twice that of cow's milk. About half the proteids of human milk 
remain in solution until they leave the stomach, while four-fifths of the 
proteids of cow's milk are precipitated in a solid curd soon after it 
enters the stomach. The relation between the quantity of lactalbumin 
and casein is a matter of great importance in determining the behavior 
of the milk when coagulated. In the presence of a considerable amount 
of soluble albumin the casein coagulates in fine flocculi, while without 
it these are much larger and show a tendency to collect in masses. 
The normal ratio between albumin and casein in human milk during 
the first month of lactation is nearly 1 to 0.8 while in cow's milk it is 
nearly 1 to 7. Camerer gives the ratio in human milk as 1 to 0.6 dur- 
ing the first month. Monti has called attention to the fact that when 
the proportion of albumin to casein is diminished the infant generally 
suffers with digestive disturbance. The proportion of total proteids in 
human milk is greater during the first weeks of lactation than after- 
ward, and the ratio of albumin to casein is greater. During the later 
months of lactation the amount of albumin falls below that of the casein. 
These differences in the composition of the proteids of human and cow's 
milk are too often lost sight of in attempts to adjust the latter to suit the 
digestion of the infant. These differences in composition and behavior 
of the proteids of the two milks explain why the the infant experiences 
so much difficulty in digesting cow's milk. But these are not the only 
differences in the proteids. Human milk contains, according to Siegfried 1 
and Stoklassa, 2 about 0.12 per cent, of nuclein, and about the same 
percentage of lecithiu, including nearly all the phosphorus of the milk in 
this organic combination. Cow's milk contains less than half as much 
nuclein and lecithin. But one-half of the phosphorus of cow's milk is 
organic or tissue-building phosphorus. From what we know of the 
nutritive value of nuclein and lecithin, it would seem that cow's milk, 
even when fed in the undiluted state, cannot nourish an infaut as well as 
human milk. Boiling or sterilizing destroys much of both the nuclein 
and lecithin of cow's milk, and greatly reduces the nutritive value of the 
milk. This will be referred to later in considering sterilized milk. 

1 Zeitschr. f. phys. Cliem., 1S96, p. 576. - Ibid., 1S97, p. 343. 



THE NEW-BORN CHILD AND ITS MANAGEMENT. 



281 



Table II. — Human and Cow's Milk Compared. 



Human Milk. 



Appearance Bluish, translucent, odorless, sweetish. 



Specific 
gravity 

Reaction 



Behavior 
on boiling 



Coagulation 



Coagulation 
with rennet 



Fat 



Relation of 
fatty acids 



Casein 



Composition 
of proteids 



Extractives 
Mineral 

matters in 

ash 



Bacteria 



1026 to 1036. 



Amphoteric or alkaline. Remains alka- 
line a long time. 

Does not coagulate, but forms a very 
slight film of albuminoid matter. 



Coagulates at ordinary temperature after 
many hours. 

Coagulates incompletely in fine flocculi, 
which never precipitate in distinctly 
visible masses. 

Yellowish- white, similar to cow's butter ; 
specific gravity at 15° C. = 0.966 ; melts 
at34°C. Composition : butyrin, caproin, 
caprin, myristin, palmitin, stearin, and 
olein. 



Relatively poor in volatile acids ; of the 
non-volatile acid sone-half is oleic ; of 
the remainder, myristic and palmitic 
predominate. 

Precipitated with difficulty by acids and 
salts ; the precipitate dissolves easily 
in excess of acids. In peptic digestion 
it leaves little residue. Contains little 
Ca 3 (P0 4 ) 2 . 

Albumin 1.1 per cent., casein 1 per cent., 
globulin 0.1 per cent., albumin to casein, 
1 to 0.8 to 1 to 2. 100 c.c contain 0.175 
gramme lecithin and 0.120 gramme nu- 
clein. Nearly all the phosphorus is in 
organic combination. 

More than in cow's milk. 
KoO NaoO CaO MgO Feo0 3 P 2 5 CI 
0.780 0.232 0.328 0.064 0.004 0.473 0.438 
Contains less ash than cow's milk. 



Generally sterile. Exceptionally a few 
staphylococci albi and s. aurei. 



Cow's Milk. 



White, opaque, 
taste. 



1030 to 1036. 



odor, and slightly sweet 



Amphoteric or acid. Rapidly becomes 
acid in the air. 

Does not coagulate, but forms a thicker 
film consisting of casein and lime salts, 
which, when removed, is rapidly re- 
newed. 

Coagulates much earlier than human 
milk. 

Coagulates at body temperature, and sep- 
arates into distinct masses, leaving a 
supernatant yellowish liquid. 

Yellowish-white mass, specific gravity at 
15° C.= 0.996 ; melts at 35.8° C. Composi- 
tion : butyrin, caproin, caprin, palmi- 
tin, stearin, olein, myristin, caprilin, 
laurin, arachin, leucitin, cholesterin, 
and yellow coloring matter. 

The volatile acids relatively large. Of the 
non- volatile acids, 3 to 4 per cent, is 
oleic ; the remainder is a mixture of 
principally palmitic and stearic. 

Easily precipitated by acids and salts; 
precipitate not easily dissolved by excess 
of acids. In pepsin digestion it leaves 
considerable residue. Contains more 
Ca 3 (P04) 2 than human milk. 

Albumin 53 per cent., casein 3 per cent., 
globulin trace, albumin to casein 1 to 6 
to 1 to 10. 100 c.c. contain 0.110 gramme 
lecithin and 0.055 gramme nuclein. Less 
than half the phosphorus in organic 
combination. 

Less than in human milk. 
K,0 NaoO CaO MgO Fe^Os P 2 5 CI 
1.72 0.510 1.98 0.200 0.003 0.820 0.980 
Contains more ash, especially CaO and PO 
Contains 6 times as much Ca 2 5 as human 

milk. 
Contains all milk bacteria, and occasion- 
ally typhoid, diphtheria, tubercular, 
and other bacteria. 



Modified Cow's Milk. The above-described differences between human 
and cow's milk make it necessary to modify the composition of the latter 
to render it available for infant feeding. No modification yet known, 
however, will bring cow's milk to agree in composition with human 
milk or make it a perfect substitute for the natural food. The modifi- 
cations of cow's milk that are most frequently practised are the fol- 
lowing : 

1. Simple dilution with water; 

2. Dilution with cereal gruels, such as barley, oatmeal, corn-starch, 
wheat-flour; or with gelatin, gum arabic, egg albumin, or sugar-water ; 

3. Dilution with water, or sugar-water, and the addition of cream ; 

4. Partial creaming, using the upper half, including the cream, and 
adding sugar-water and lime-water ; 



282 PHYSIOLOGY OF THE PUEPPEEIUJL 

5. Removing a part of the casein by means of rennin or by the cen- 
trifugal machine; 

6. Partial peptonizing of the proteids, and dilution with water; 

7. Mixtures of milk, cream, sugar, and water, made according to chem- 
ical analysis, to contain a known percentage of each constituent. 

Dilution with water, to the extent required by the excess of proteids in 
cow's milk, reduces the fat and sugar below the proportion necessary for 
the nutrition of the infant, and such modification alone is seldom suc- 
cessful. 

The Author's Methods of Modifying Cow's Milk. The only rational 
and practical household method of modifying cow's milk for infant 
feeding is to dilute the milk so as to reduce the casein to 1 per cent, or 
less, then to add cream to bring the fat up to 3 or 3.5 per cent., and 
milk sugar to bring this constituent to 6 per cent. The simplest and 
most practicable method of doing this is as follows : 

"When the milk is received it is allowed to stand in a cool place for 
three hours. When the milk is received in bottles, as is now the cus- 

Fig. 212. 



Method of siphoning off the under milk. 

torn, it is better to remove the bottom milk by means of a siphon, con- 
sisting of a piece of small rubber tubing about eighteen inches long, 
leaving the cream layer and top milk undisturbed in the bottle (Fig. 212). 

When two-thirds of the contents of the bottle are thus drawn off, the 
remaining portion will have approximately 7.5 to 8 per cent, of fat, 4 
per cent, of proteids, and 4.5 per cent, of sugar. 

When one-half of the milk is thus drawn off, the remainder will have, 
when shaken up, about the following composition : Fat, 5 to 6.5 per 
cent. ; proteids, about 4 per cent. ; sugar, 4.5 per cent. 

Directions for Preparing a Near Imitation of Human Milk from Cow's 
Milk. " Siphon off from the bottom of a bottle of fresh milk of good 
quality three-fourths of its contents, leaving the cream and upper part 
of the milk undisturbed in the bottle. This may easily be done with a 
small glass siphon or rubber tubing, previously filled with water, to 
start the siphonage. Pinch one end of the rubber tube and hold it 



THE NEW-BORN CHILD AND ITS MANAGEMENT. 283 

firmly, while the other is thrust through the cream and to the bottom 
of the bottle. Lower the outer end into a suitable vessel, or, better, 
into the inner vessel of an ordinary double boiler, and release it, when 
the skim-milk will run out, provided the latter vessel is kept lower 
than the milk in the bottle. To the milk thus drawn off add a tea- 
spoonful and a half of good essence of pepsin, or one or two junket 
tablets, and warm slowly in the double boiler to blood-heat, and keep 
at that temperature until thoroughly curdled. Now heat, with constant 
stirring, until a thermometer dipped into the milk shows a temperature 
of 155° F., and remove from the fire. Strain, while hot, through clean 
wire strainer and dissolve in the whey a heaping tablespoonful of sugar 
of milk. When cold, pour the sweetened whey back into the milk 
bottle and mix thoroughly with the cream and top milk. Pasteurize 
the mixture in a Freeman's pasteurizer. The composition of this food 
will be about as follows : Fat, 3 to 3.5 per cent.; caseinogen, 0.9 per 
cent; albumin, 0.75 per cent.; sugar, 6 per cent.; extractives, 0.26 per 
cent.; ash, 0.7 per cent.; total solids, 11.66 per cent.; water, 88.34 per 
cent. On comparing this with the analysis of human milk in the above 
table of composition, it will be seen to correspond very nearly with it. 

" The close resemblance of this mixture to human milk is seen by com- 
parison. This mixture will, if properly made, correspond more nearly 
in composition to human milk than any other known to the author. 
One very important consideration in regard to this food is the relation 
between the casein and the iactalbumin, which, while it is not exactly 
that of human milk, corresponds more nearly to it than can be attained 
by any other method of dilution. This is very important in its effect 
on the consistence of the curd. This mixture, when coagulated with 
acid, behaves very strikingly like human milk. The fat has not been 
removed from the milk, and, therefore, the emulsion has not been de- 
stroyed, as is the case in all mixtures made with centrifugal cream. 

" An extensive experience with this food has shown it to give good 
clinical results. It is palatable, agrees with most infants, and promotes 
growth and development quite satisfactorily. 

" Note. — Should this food prove too laxative, reduce the quantity of 
milk-sugar. It is well to add, at the time of feeding, from one to two 
teaspoonfuls of lime-water to each meal. As the child increases in age 
and strength the amount of bottom milk siphoned off may be dimin- 
ished." 

I have, at times, found it necessary to show the mother how to con- 
duct the process, but only mothers below the average intelligence. 

One great benefit of this process is its pliability, or the ease with which 
the constituents may be varied. If we wish to reduce caseinogen, we 
draw off more of the bottom milk. To increase it, draw off less. To 
decrease the fat, dip off a part of the cream, remembering that the 
whole amount of cream measures from ten to twelve tablespoonfuls ; 
to increase the fat, add a little less than the full amount of whey, 
after removing the curd. To increase the soluble albumin, add white 
of egg. The sugar may be varied at will, by adding more or less, as 
desired. 

It will occasionally be found, even with a food in which the casein 
has been reduced, by one of the above methods, to one-third or one- 



284 PHYSIOLOGY OF TBI: PUERPERIUM. 

fourth that found in cow's milk, that curds will appear in the stools 
of the infant. In such cases a little white-of-egg water or barley gruel 
added to the food may promote the disintegration and digestion of the 
curds. 

When egg-albumin is added to the food, the egg must be as fresh as 
possible, and it may be added in the proportion of the white of one egg 
to a quart of food. This will add about 3 grams of albumin to the 
quart, or approximately 0.3 per cent, of soluble albumin, increasing 
that constituent in this food to about 1 per cent., or to that found in 
human milk. Unless the egg used is fresh, this addition may at times, 
especially in hot weather, tend to produce putridity of the infant's stools. 

Peptonized Milk. In some cases partial peptonization may be neces- 
sary. This is accomplished by the following process : To a pint of the 
milk add 5 grains of extractum pancreatitis and 15 grains of sodium 
bicarbonate. Warm the milk slowly to 104° F., and keep it at that 
temperature for ten minutes, then bring it nearly to the boiling-point, 
to destroy the ferment. Instead of heating the milk to the higher 
temperature, it may be placed at once on ice. Peptonization may do 
good for a short time, but experience has shown that it is rarely well 
borne when long continued. It seems better to allow the digestive 
juices of the infant to accomplish the necessary changes in the food 
than to induce them outside of the body. If predigestion is practised 
at all, the process should not be carried beyond a partial digestion. This 
principle applies with equal force to all the predigested or partially 
digested foods of the markets. Experience has showm that none of them 
is successful except for a time. 

Cream Mixtures. The results obtainable with the mixtures above 
described will be better, as a rule, than with home-made mixtures of 
milk, cream, and water, because the best obtainable cream, in large cities, 
is usually decidedly acid and teeming with milk bacteria. This is 
especially true of gravity cream. Preparations made with such cream 
are very liable to produce acid fermentation in the infant's stomach, 
with vomiting. Centrifugal cream, when fresh, has the advantage that 
it is usually fairly uniform in composition, and may be obtained of 
known fat content. It has the disadvantage that the natural emulsion 
is broken up by the process of separation, the fat globules being collected 
in small lumps. The fat is, consequently, less easily digested by the 
infant. This objection is a serious one when the cream is kept some 
time after the separation, before using. 

Mixtures of milk, cream, water, sugar, and lime-water have been 
recommended by Biedert, Meigs, Potch, and others for many years. 
Potch's mixture differs from that of Meigs principally in containing 
less lime-water. It is made as follows : 

Cream (20 per cent, of fat) 1]4 ounces. 

Milk 1 ounce. 

Milk-sugar 3% drachms. 

Water 5 ounces. 

Lime-water }4 ounce. 

Vigier's Method. A method of preparing a close imitation of human 
milk, suggested by Yigier in 1893, is as follows : Divide a quart of 



Casein. 


Albumin. 


Fat. 


Sugar. 


Salts. 


1.22 


0.66 


2.33 


4.5 


0.7 


1.61 


0.61 


3.11 


4.5 


0.7 



THE NEW-BORN CHILD AND ITS MANAGEMENT. 285 

milk into two equal portions. Let both stand three or four hours 
in a cool place, skim the cream from one portion and add this to 
the other. To the skimmed portion add a teaspoonful of liquid 
rennet; warm to 35° to 40° C. (95° to 104° F.) for fifteen to twenty 
minutes, with frequent stirring, or until it forms a tough curd. 
Then heat to 68° C. (155° F.) and strain through muslin and cool. 
The whey so prepared from good milk will contain, of casein, 0.03 per 
cent.; albumin, 0.80 per cent.; fat, 1 per cent.; sugar, 4.5 per cent., 
and salts, 0.70 per cent. It contains a little more soluble proteid than 
the milk from which it is prepared. For infants under five months of 
age, mix equal volumes of this whey and the enriched milk; for infants 
over five months, mix two parts of milk with one of whey. The com- 
position of this food will be nearly as follows, expressed in percentages: 

Equal volumes of whey and milk 
Two parts milk and one part whey 

Average human milk . . . 1.03 1.20 3.90 6 04 0.4 

Monti uses a mixture of whey and milk, in the proportion of equal 
volumes for the first three months ; after that time he uses a mixture of 
two parts of milk and one of whey. 

Chapin, of New York, prepares an infant food by home modification 
of cows' milk by dipping the cream from a bottle of market milk with a 
special dipper holding one ounce. By removing in this way nine dipper- 
fills from the top of a quart bottle there are obtained nine ounces of a 
rich milk, containing approximately 12 per cent, of fat and 4 per cent, 
of total proteids. This is then diluted with dextrinized cereal gruel suf- 
ficient to make thirty-six ounces. The composition of this food will be 
approximately : Fat, 3 per cent.; milk-proteids, 1 per cent.; sugar, 1.1 
per cent.; of dextrin, cellulose, cereal-proteids, and salts, an unknown 
amount. Milk-sugar is added to increase this constituent to about 6 
per cent. To increase the amount of milk-proteids in the finished 
product, it is only necessary to dip off more dipperfuls of the top 
milk, and add less than three times as much gruel. To increase the 
fat without increasing the proteids, a less amount of cream is dipped 
out, say six ounces. He shows that this cream, if carefully dipped 
from the cream layer of an ordinary quart bottle of well-creamed 
milk, will contain about 20 per cent, of cream and about 4 per cent, of 
proteids. If to this cream four volumes of diluent are added, the mixt- 
ure will contain about 0.8 per cent, of proteids and 5 per cent, of fat. 
The sugar will be reduced to about 0.9 per cent., and 5 per cent, of sugar 
must be added, or a little over 1.5 ounces. 

In this method of modifying cows' milk the author believes that the 
casein is not only reduced to such a quantity that the infant can digest 
it, but that it is rendered more digestible by the fact that the coagula 
are rendered flocculent and easily disintegrated by the presence of 
dextrin and the presence of the soluble proteids of the cereal. The 
soluble proteid is increased by the gruel, especially when oatmeal or 
barley is used, and thus the ratio between this and the casein is made 
more nearly like that of human milk, although the amount added is 
necessarily an unknown quantity. The carbohydrate content of this 
food is increased by the addition of dextrin and maltose, so that this 



286 PHYSIOLOGY OF THE PUERPERIUM. 

constituent is out of the natural proportion as found in human milk. 
When prepared by unskilled hands the quantity of maltose formed must 
vary somewhat ; but its presence ought to make the addition of sugar 
unnecessary, could we know how much sugar is thus added. 

Gartner's Milk. Gartner, of Vienna, has recently placed upon the 
market a milk containing one-half the normal proportion of casein in 
cow's milk while retaining nearly the full percentage of fat. 

The relation of albumin to casein in this milk is as 1 to 7, or the same 
as that obtained by diluting milk with an equal volume of water. The 
milk, then, has nearly the following composition, expressed in percent- 
ages: Casein, 1.75; albumin, 0.27; fat, 3; sugar, 2.25, and salts, 0.35. 
Its reaction is faintly acid; its specific gravity is 1020 to 1025, and it 
has a pleasant, though feebly sweet taste. The latter defect is met by 
the addition of milk-sugar. It coagulates with acid in finer flocculi 
than cow's milk, and has been used with some success in infant feeding. 
It has the disadvantage that the relation of soluble albumin to the casein 
is that of cow's milk, and not that of human milk. In this respect it is 
inferior to the mixture of whey and milk above described. It has the 
further disadvantage that the fat globules conglomerate into masses, 
which cannot afterward be emulsified again, rendering the fat difficult of 
digestion. It is supplied in the markets in tin cans, like condensed milk, 
and is previously sterilized by heat. It, therefore, has all the disadvan- 
tages of sterilized milk, mentioned under that heading. 

The Mechanical Method of modifying milk consists in adding thin gruels, 
made with the cereal grains or dextrin, to cow's milk. They attenuate 
the clot of casein, so that it becomes more floeculent, like that of woman's 
milk. Barley-water is most commonly used for this purpose. The only 
disadvantage in giving it to very young infants is due to the starch it con- 
tains. Before the third month, owing to the fact that the salivary and 
pancreatic glands are slightly developed, very little starch can be digested. 
Most of the prepared infant foods contain too much unchanged starch for 
a young infant's digestion. What is desired is a flour containing the 
albuminoid constituents of the grain, carbohydrates, in soluble form, 
and but little of the insoluble starch. 

Sterilized Milk. In all large cities, and whenever cow' s milk cannot 
be obtained "fresh from the cow" twice a day, it is necessary to 
adopt some means of checking the fermentative changes in it. Ex- 
periments show that cow's milk when first drawn from the udder, 
under the usual conditions, contains from forty to several hundred bac- 
teria in each cubic centimetre. After six hours it contains from 5000 to 
10,000 in each cubic centimetre. These bacteria multiply very rapidly, 
producing detrimental changes in the milk, unless their growth is checked 
by a very low temperature, by the use of antiseptics, or by the application 
of heat. The well-known process of sterilization consists in heating the 
milk to 100° C, 212° F., for a sufficient time to destroy the bacteria, 
and most of the spores of bacteria, without producing too great changes 
in the taste of the milk. In practice, the time of heating varies from 
fifteen to forty-five minutes. Complete sterilization can be accomplished 
only by heating the milk to 110° C. for fifteen minutes. 

Sterilization at 100° C. produces the following changes in the milk, 
which are undesirable : 



THE XEW-BOEX CHILD AXD ITS MAX AG EM EXT. 



28' 



1. A part of the sugar is decomposed or caramelized, giving the milk 
a disagreeable taste; 

2. The fat is melted, the emulsion largely destroyed and rendered less 
digestible; 

3. The casein is changed, so as to be less easily affected by rennet, and 
when coagulated it forms tough indigestible curds, which may be found 
in the stools; 

4. The albumin and globulin are coagulated, and made capable of 
precipitation with the acids of the gastric juice, thus increasing the size 
and toughness of the curd formed in the stomach, and making it less 
easily digestible; 

5. The nuclein and lecithin of the milk are largely destroyed, and the 
peculiar nutritive function of these bodies is lost. It is probable that this 
is the cause of the loss of antiscorbutic properties in sterilized and in 
condensed milks ; 

6. The salts are rendered more insoluble; especially is this true of the 
phosphates. 

Children fed exclusively upon sterilized milk fail to thrive as well 
as when fed upon unsterilized milk, and show a tendency to develop 
rachitis. 

The advantages of sterilized milk are : 

1. The destruction of disease germs; 

2. The prevention, to a great extent, of the accidents due to sour milk; 

3. The increased keeping quality of the milk, without ice, and on long 
journeys. 

Pasteurization or Partial Sterilization at a temperature not exceeding 
70° C, 158° F., has now practically superseded complete sterilization. 



Fig. 213. 



Fig. 214. 




Freeman's Pasteurizer. 




Arnold's milk sterilizer. 



Most proteids coagulate at 73° C. to 75° C. (163.4° F. to 167° F.), 
while lactalbumin coagulates at 77° C. (170.6° F.). The temperature 
should not, therefore, be allowed to reach 77° C. (170.6° F.). This 
temperature is above the thermal death-point of the lactic-acid ferment 
and of most pathogenic organisms. The bacillus tuberculosis, the 



288 PHYSIOLOGY OF THE PUERPERIUM. 

bacillus typhosis, bacillus diphtheria?, aud bacterium lactis are all killed 
by fifteen minutes' exposure to a temperature of 65° C. (149° F.). 

The simplest and most practical Pasteurizer in the market is that 
devised by Dr. Freeman, of New York, Fig. 213. It consists of a 
tin pail provided with a groove to indicate the amount of water to be 
added. The water is heated to boiling on an ordinary cooking-stove. 
The milk, contained in bottles plugged with cotton, is placed in the zinc 
cylinders of the rack, the space about them filled with water, and lowered 
into the boiling water, the cover put on, and the pail removed from the 
stove. The latent heat of the water is just sufficient to heat the milk to 
about 68° C. (154.4° F.), when all the bottles are filled. After half an 
hour the cover is removed, the rack containing the bottles is raised partly 
out of the water, and cold water run into the pail until the milk is cold. 
This process will greatly increase the keeping quality of the milk with- 
out perceptibly changing its chemical properties or taste. Arnold's milk 
sterilizer, too, may be used for pasteurizing, but it is not so easy to 
secure a fixed and certain regulation of the temperature. The temper- 
ature varies with the rapidity of the boiling of the water (Fig. 214). 

Condensed Milk. Condensed milk has been a popular food for infants 
ever since its introduction. The canned milk which contains cane- 
sugar added as a preservative is most commonly used. The makers 
claim that such milk is condensed to one-fourth the original volume, 
but analysis shows that it is usually condensed to one-third — i. e., when 
diluted with two volumes of water it will give a liquid containing the 
same percentages of milk-solids as the original milk, together with about 
12 to 13 per cent, of cane-sugar. Meigs has shown that when one part 
of the best commercial sweetened condensed milk is diluted with nine 
parts of water, the mixture somewhat closely corresponds in composition 
with human milk, with the exception that it is deficient in fat and con- 
tains cane-sugar for a part of the lactose. A mixture of one part of 
condensed milk, one part of Pasteurized cream (containing 12 per cent, 
of fat), and eight of water, more closely resembles human milk in com- 
position. While many infants will apparently thrive on this mixture, it 
has all the disadvantages of sterilized milk, and infants fed upon it almost 
invariably sooner or later show signs of rachitis. 

It should be remembered that sterilization and pasteurization are sani- 
tary measures used to protect infants from dirty or contaminated milk. 
When a clean, pure fresh milk is to be had they should not be em- 
ployed, as the infant will thrive better on the raw milk. 

Milk Laboratories. During the past few years milk laboratories have 
been established in some of the large cities, with the object of securing 
greater accuracy in the artificial feeding of young infants. The W r alker- 
Gorden Company were the pioneers in this field, and are now operating 
laboratories in New York, Philadelphia, Boston, Chicago, Baltimore, 
and Montreal. The physician writes directions for an infant's food, 
and sends them to these laboratories, just as he orders drugs by pre- 
scription. 

It is found that slight changes in the percentages of fat, sugar, and 
proteids may be of great value in managing cases of indigestion and 
malnutrition in the infant. The following is Dr. Kotch's working basis, 
deduced from the study of normal average breast milks for the first three 



THE NEW-BORN CHILD AND ITS MANAGEMENT. 289 

months of life. It must be understood, however, that these figures may 
require modification to suit individual cases. 

I. II. in. iv. v. 

Fat 2 00 2.50 3.00 3.50 4.00 

Milk-sugar .... 5.00 6.00 6.00 6.50 7.00 

Albuminoids .... 0.75 1.00 1.00 1.50 1.50 

Mineral matter . . . . 0.11 0.17 0.17 0.25 0.25 

Total solids .... 7.86 9.67 1017 11.75 12.65 

Water 93.14 90.33 89.83 88.25 87.25 

The following may be given as a sample prescription to be tried for a 
new-born infant after the second day: 

Fat 2 per cent. 

Sugar 5 " 

Proteids 0.75 " 

Lime-water 5 " 

Number of feedings 10 

Put up in ten bottles, each containing one and a half ounce. Pas- 
teurize at 167° F. for fifteen minutes. 

Should this mixture agree the sugar and fat should be increased at the 
end of the first week by one-half per cent. The sugar may be increased 
to 6 per cent, at the end of the second week, unless the child has colic. 
It is not always easy to determine the cause of the disagreement, but a 
few trials with varying percentages of fat, proteids, and sugar will enable 
the practitioner to adapt the food to the needs of the individual case. 

It will seldom be necessary to depart from the known variations in 
human milk, as given in the table on page 274. 

Too large a percentage of sugar may cause greenish, acid stools and 
colic, and too low a percentage will usually lead to dry stools and 
failure of the proper increase in weight. 

Too large a percentage of fat may give rise to vomiting, diarrhoea, and 
fatty masses in the stools. In some cases an excess of fat may cause 
colic. A deficiency of fat frequently occasions constipation, with dry, 
hard stools. The fat should rarely be increased above 4 per cent., and 
it is seldom that more than 3.5 per cent, is necessary. 

An excess of casein is the most frequent cause of digestive disturbance 
in bottle-fed infants. The casein should never be more than 1 per cent, 
to begin with, and in most cases less than this will be found to give the 
best results. 

The most certain indication of too large an amount of casein is the 
presence of curds in the stools. It must be remembered that free fatty 
acids so closely resemble curds as to deceive the naked eye. In such cases 
the stools are strongly acid^ and they irritate the nates and genitals, caus- 
ing erythema. These lumps of fat or fatty acids are soluble in ether, 
while the casein lumps are insoluble in that reagent. 

Sometimes the child is unable to digest even a very small amount of 
casein. 

We have already called attention to the importance of a proper rela- 
tion between the percentages of albumin and casein. The addition of a 
small amount of egg-albumin to the food will sometimes assist in the 
digestion of the casein. If we attempt to correct the proteid indiges- 
tion by reducing the proportion of albuminoids, the child may suffer 
for want of nitrogenous food. 

19 



290 PHYSIOLOGY OF THE PUERPEBIUM. 

It is to be remembered that human milk contains nearly 2 per cent, of 
proteids, while colostrum, according to Pfeiffer, contains 9 per cent, of 
proteids on the first day after parturition, 7 per cent, on the second day, 
and 2.36 per cent, on the eighth day. Heubner gives the percentage 
of total proteids during the first week as from 2 to 3.2 per cent. Nearly 
the whole of these proteids is in the form of albumin and globulin, 
while the milk prepared at the milk laboratories contains but a trace of 
albumin. This large proportion of albumin to casein in human milk 
assists materially in preventing firm coagulation of the casein. 

The term albuminoids in the above table might with propriety be 
changed to casein, for the reduced proportion is secured by diluting 
cow's milk, which contains about 0.5 per cent, of albumin. To reduce 
the casein to 1 per cent, the milk, and consequently the albumin, must 
be diluted three and a half times with water. This will reduce the albu- 
min in such a mixture to 0.1 per cent. 

If we wish to make the casein of cow's milk behave, on coagulation, 
like human casein, we must dilute the milk with five parts of water, 
thus reducing the casein to about 0.6 per cent. This proportion of 
proteid is too small to afford a proper amount of nitrogenous food for 
the child. Egg-albumin is sometimes used to supply soluble albumin 
to the milk foods. The author has seen good results from this addition 
to modified milk. Egg-albumin is slightly different in composition and 
properties from lactalbumin, and raw-egg albumin may not digest as 
readily as lactalbumin. Experience has not demonstrated the unfitness 
of fresh egg-albumin water as a diluent in modifying milk. We have 
already insisted upon the absolute freshness of the eggs used to furnish 
the albumin. 

The objections to the use of centrifugal cream have already been stated. 

AYe may repeat here the statement that a process for preparing an 
exact substitute for mother's milk has not yet been devised. 

The Nursing Bottle. One of the most important points in artificial 
feeding is scrupulous cleanliness of bottle and nipple. The long rubber 
tube connecting the bottle with the nipple must be discarded, and the 
bottle itself should be as round and tube-like as possible, to avoid angles 
in which sour milk may collect. The nipple should be a simple rubber 
cone with several very small openings at the end. These openings should 
require suction on the part of the infant to bring out the milk. If, upon 
inverting the bottle, milk streams through the nipple, the latter is unsuit- 
able for use; the fluid runs too freely iuto the infant's stomach, and 
indigestion is likely to result. Both bottle and nipple must be scalded 
after using, and when not in use be kept in a solution of boric acid in 
water, or some other mild antiseptic solution. 

Amount and Frequency of Feeding. The amount of fluid to be given at 
each meal and the interval between meals are matters of great importance. 
Irregular and hap-hazard feeding should not be countenanced. The phy- 
sician should direct these matters as minutely as possible, giving detailed 
directions as to the preparation of the food, its preservation until needed, 
the kind, size, and form of bottle, and the amount and time of feeding. 

In breast-feeding the quantity of fluid taken is determined by the 
quantity secreted, and usually regulates itself. Sometimes, however, the 
amount secreted is too great for the needs of the infant, and at others it 



THE NEW-BORN CHILD AND ITS MANAGEMENT 



291 



is not enough. In bottle-feeding the tendency is to feed too much and 
too often. Overfeeding is much more harmful than underfeeding, and 
is the most frequent cause of gastro-intestinal disturbance in bottle-fed 
infants. The capacity of the stomach in infancy is subject to consider- 
able variation, but, as a general rule, the gastric capacity of a child 
during the first month is one-hundredth the child's body-weight — i. e., 
the greater the weight the greater the gastric capacity. Numerous 
measurements of the stomach -capacity of infants, by different observers, 
as well as practical experience, have shown that the amount to be given 
at each feeding, the intervals between feedings, and the number of feed- 
ings in each day, are about those set forth in the following table. It 
must be understood, however, that these figures may need to be modified 
to suit individual cases : 







No. of 


Amount 


Amount 


Age. 


Interval. 


feedings 


of each 


in 






in 24 hrs. 


feeding. 


24 hours. 


First week, 


2 hours. 


10 


1 ounce 


10 ounces. 


1 to 6 weeks, 


2 


10 


V/ 2 to 23^ ounces. 


15 to 24 ounces. 


6 to 12 '• 


2V 2 " 


8 


2^ to ay 2 " 


20 to 28 


3 to 6 months, 


2% to 3 hours. 


6 


4 to 5% 


24 to 32 


6 to 9 " 


3 hours. 


6 


6 ounces. 


36 ounces. 


9 to 12 " 


3 


5 


8 


40 



Gavage, or Forced Feeding. It becomes necessary at times to feed an 
infant, or even older children, by the forcible introduction of food into 
the stomach through a tube. Although this method of feeding has been 
practised for a long time in some European countries, its advantages have 
not until recently been fully appreciated in this country. 

The method of practising gavage is very simple. The apparatus used 
is the same as that for stomach washing, and consists of a soft-rubber 
catheter, 12 to 16, American scale, or 24 French scale, a small funnel, 
two feet of rubber tubing, and a piece of glass tubing about three inches 
long to connect the rubber tubing to the catheter. The child is placed 
upon its back, the catheter is quickly introduced, the funnel raised so as 
to straighten the rubber connecting tube, and the food poured into the 
funnel. As soon as the food has almost all run down, the tube is 
pinched, to prevent the milk from trickling into the pharynx as the tube 
is removed, and it is then quickly withdrawn. The child should be kept 
absolutely quiet after feeding by this method. Should it offer much 
resistance to the introduction of the tube, the latter may be passed 
through the nose. In older children a mouth -gag is often necessary. 
If the food is regurgitated or vomited, the tube should be introduced a 
second time, and another feeding given. The intervals between feedings 
are generally longer when gavage is practised than under other circum- 
stances. When this method is employed in feeding premature or feeble 
infants, the food should usually be predigested; if the mother's milk can 
be used this is unnecessary. It is well to wash the stomach before the 
first feeding, and at least once a day afterward while gavage is practised. 

In connection with the incubator gavage has been found of great 
advantage in feeding premature infants; also after operations upon the 
throat and nose, and in other conditions in which the child may refuse 
food. The food is not often vomited when thus introduced, even when 
not retained in the usual method of feeding. 

Signs of Normal Nutrition. The best index of the nutrition of an infant 



292 



PHYSIOLOGY OF THE PUERPERIUM. 



is the rate of iucrease in weight. The study of the child's nutrition 
requires frequent weighing. The weight of the average infant at birth 
is, according to J. Lewis Smith, seven pounds and four ounces for girls, 
and seven pounds and eleven ounces for boys. Others place the weight 
slightly lower, with less difference between the sexes. During the first 
three or four days there is a loss in weight of six to ten ounces, which is 
regained by the middle of the second week. A loss of twelve ounces, 
or a failure to regain the birth-weight by the beginning of the third 
Aveek, at the latest, calls for careful investigation. 

After the second week the weight should increase regularly, the child 
doubling its birth-weight by the end of the fifth month. While the rate 
of increase differs very considerably, a child that is not gaining five 
ounces a week cannot be said to be thriving as it ought. The accom- 
panying chart, from Holt, shows the rate of increase in weight of the 
average well-nourished infant during the first year. (Fig. 215.) 

The Feces. The character and amount of the stools of an infant often 
give an important indication of the quantity of food taken and the degree 
of digestion. They also give valuable information as to the cause of loss 
of weight and the character of the digestive disorder. 

The stools of the new-born infant are greenish-black in color, and are 
termed meconium. Meconium is composed of intestinal mucus, bile, 
vernix caseosa, epithelium cells, hair, fat, cholesterin crystals, and cal- 
cium and magnesium phosphates. It is free from bacteria immediately 
after birth. On the third to the fourth day the stools change to a lighter 
color, and by the fifth day are lemon-yellow. 



Fig. 215. 
WEEKS OF AGE. 



GRMS. 


| 


1 


2 


4 





8 


10 


12 


14 


Itt 


18 


20 


22 


24 


26 


28 


30 


32 


34 


30 


38 


40 


42 


44 


40 


48 


50 


52 


9070 


20 
























































8620 


19 
























































8160 


is 
























































7710 


i: 
























































7260 


Hi 
























































6800 


15 
























































6350 


14 
























































5900 


13 
























































5440 


12 
























































4990 


11 
























































4540 


10 
























































4080 


9 
























































3630 


8 
























































3180 


7 
























































2720 


6 
























































2270 


5 
























































1810 


4 

























































Normally the stools at this time are from three to four in twenty- 
four hours, smooth, semi-solid in consistence, nearly homogeneous in 
appearance, and have a slightly acid, not unpleasant odor. They con- 
tain fat, free fatty acids, calcium lactate, and a small amount of casein. 



THE NEW-BORN CHILI) AND ITS MANAGEMENT. 293 

The reaction of the feces is usually acid, but is sometimes neutral or even 
alkaline. The cause of the acidity is the presence of fatty acids, lactic 
acid, and sometimes butyric. The degree of acidity varies considerably, 
yet excess of lactic and butyric acids may be considered pathological. 
The yellow color is due to bilirubin. 

In diseased conditions the stools often become green, which color is 
usually attributed to biliverdin, but there is some doubt upon this point. 
Opposed to this idea is the fact that the stools are often yellow when 
passed, but become green on exposure to the air, while biliverdin on 
oxidation yields bilirubin, which is yellow and not green. In some 
cases at least the green color appears to be the result of fermentative 
processes, and to be caused by the excessive production of lactic acid and 
the action of this upon the biliary coloring matters. 

There will usually be found with the green-colored stools more or less 
undigested casein, pseudo-nuclein, and free fatty acids. These appear 
as white masses distributed through the feces. Fat may be distinguished 
from casein by its solubility in a mixture of alcohol and ether. 

The normal stool of a nursing infant contains about 85 per cent, of 
water, 2 to 3 per cent, of fat, 0.2 per cent, of proteids, and 0.1 to 0.2 
per cent, of cholesterin. 

Excessively acid stools often irritate the nates and genitals, producing 
a troublesome erythema. 

The stools of infants fed upon cow's milk do not differ materially 
from those of breast-fed children, except that the amount is much 
larger, and they are more liable to contain caseous masses of large size, 
especially when sterilized milk is used. 

Dry and pasty stools or an insufficient amount of fecal matter are 
often indications of a deficient supply of food. An excessive quantity 
of fecal matter is usually the result of overfeeding. 

Starch will often be found in the stools of infants fed upon cereal foods. 
Its presence may readily be shown by its blue color reaction with iodine. 
Mucus is contained in the stools in catarrhal enteritis or intestinal in- 
fection. The stools of infants are sometimes offensive in odor. Such 
stools indicate proteid decomposition. This decomposition is usually 
caused by the excessive growth of the Bacillus proteus vulgaris. This 
bacillus is antagonized by the lactic acid ferment, Bacillus lactis aero- 
genes, and by the lactic acid produced by it. A variety of other micro- 
organisms are found in infants stools, such as the bacillus coli commu- 
nis, micrococci, yeast-cells, etc. 

A careful inspection of the stools should be made in all cases in 
which there is reason to suspect any form of digestive disorder. 

Care of Prematurely Born Infants. 

Infants born before term require greater care than full-term children. 
Those born before the sixth month rarely if ever live. Of those born 
during the sixth month, a small proportion have sufficient vitality to 
survive, with proper care and attention. The prognosis will vary with 
the degree of prematurity and the development of the child. When 
but a few weeks are lacking to complete the full term, little extra care 
may be necessary. It is well, however, in such cases to omit the usual 



294 PHYSIOLOGY OF THE PVERPERIUM. 

bath, apply a liberal coating of sweet oil to the skin, after washing the 
face, and use extra precautions to keep the infant warm. If the circu- 
lation is good and the cry vigorous, the child may be dressed; otherwise, 
it should be wrapped in cotton, and all exposure and handling deferred 
until later. In some cases the infant may be so feeble as to require the 
application of artificial heat to maintain its vitality. This will be indi- 
cated by cold and cyanotic extremities, feeble cry, and inability to nurse. 

Incubators. Artificial heat may be applied by rolling the infant in 
blankets and placing a few bottles filled with water at a temperature of 
105° F. in the blanket with it. A much better method is the use of 
an incubator. In private practice the physician may be called upon to 
improvise an incubator. It is a matter of the greatest importance that 
whatever measures are to be adopted to supply heat, they should be 
utilized as soon as possible. A simple, practical incubator may be con- 
structed from a soap or candle box. Half -inch auger-holes are bored in 
the sides of the box about six inches above the bottom, and a pillow or 
other suitable bed is placed in the box, upon which the infant is laid, 
wrapped in cotton. The heat may be supplied by means of bottles filled 
with hot water and placed within the box. 

The author has used an improvised incubator constructed as follows : 
There is required first a packing-box of suitable size, about 18 x 24 x 10 
inches, and a piece of three-inch lead pipe, bent, as shown in Fig. 216. 
The longer arm of the pipe should be about the length of the box and 
the other a little shorter than its height. The end of the shorter arm is 
cut at an angle of sixty degrees. An opening is provided in one corner 
of the bottom of the box, larger than the pipe, and another in the oppo- 
site end near the top and at the corresponding side of the box. (Figs. 216 
and 217.) The opening in the bottom of the box is covered with a plate 
of tin. The latter is provided with an opening large enough to receive 
the chimney of a kerosene lamp. The box is supported on two chairs, the 
pipe is put in place, with the long arm projecting an inch or two from the 
end of the incubator, and the short arm resting upon the tin plate cover- 
ing the hole in the bottom. The pipe is protected by a piece of wire 
netting, folded over it and tacked to the side of the box. A series of 
auger-holes are bored near the top edge of the sides and at one end of 
the box, to admit air, and a glass plate is used to cover it. An ordinary 
kerosene lamp supplies the heat. The chimney of the lamp is passed 
through the hole in the tin plate, and well up into the pipe, so that no 
gases from the lamp can enter the box. The heat of the lamp creates 
a strong draught in the pipe, which not only carries off its own gases, 
but draws the air from the box through the open lower end of the pipe. 
The temperature of the air-chamber is regulated with a thermometer 
placed within by the side of the child. By raising or lowering the wick 
of the lamp the temperature can be raised or lowered, and can be adjusted 
to any desired degree. Moisture may be supplied to the air-chamber by 
hanging a wet sponge to the side of the box at any convenient place. 

AVhen once regulated it may safely be managed by any nurse, whether 
skilled or not. This is a matter of considerable importance in private 
practice. 

The temperature of the incubator for verv feeble infants should be 



THE NEW-BORN CHILD AND ITS MANAGEMENT. 295 

Fig. 216. 




Bartley's incubator. Longitudinal vertical section. 



Fig. 217. 




Bartley's incubator. Transverse vertical section. 



kept at about 35° C. to 37° C, 95° to 98.6° F. For those a little 
stronger it may be from 30° C. to 35° C, SQ° F. to 95° F. 



296 



PHYSIOLOGY OF THE PUERPERIUM. 



An excellent incubator has been devised by Holt. (Fig. 218.) It is 
a modification of Tarnier's apparatus, and is less complicated and less 
expensive than many others that have been described. It consists of a 
double-walled box, thirty inches long, fifteen wide, and twenty high, with 



Fig. 218. 




Incubator. (Holt.) 



a one-fourth inch air space between the inner and outer walls. A tank 
of warm water, four inches deep and covering the bottom of the box, 
supplies the heat to maintain the requisite temperature. A loop of 



Fig. 219. 
Glass Cover 



Air Exit 




Vertical section of incubator, showing internal construction. (Holt.) 



brass pipe is connected with one end of the tank, and this is provided 
with a funnel for filling and a faucet for emptying the tank. The water 



THE NEW-BORN CHILD AND ITS MANAGEMENT. 297 

is heated by a Bunsen burner placed upon a shelf under the loop of 
pipe. The tank holds five or six gallons of water. Fresh air is ad- 
mitted by four openings, three inches in diameter, two on each side of the 
box; a slide is so arranged as to regulate the admission of air at will. 
About six inches above the tank there is a shelf which serves as the 
support for the child's bed; a clear space of six inches is left at one 
end of the shelf. The air enters the openings above described, passes 
over the tank, then over a wet sponge and out at the top of the box. 
The internal construction is shown in Fig. 219. The top consists of a 
plate of glass, which may be pushed aside to admit of feeding the child 
without removing it from the incubator. The temperature is regulated 
by a thermometer. The infant lies upon a bed of cotton and enveloped 
in cotton. It is usually removed once daily for cleansing the chamber 
and renewing the cotton. 

Holt says there is some difficulty in maintainiog good ventilation with 
the room temperature at 75° F. or higher, but none at65°to68°F. 

Rotch, of Boston, has devised a more complicated apparatus, but its 
expense is such that few will care to purchase it. 

The Feeding of a premature infant will require special care. If left 
to itself it will not nurse from the mother, or from a bottle, in many 
cases. It may be necessary to feed it with a medicine dropper, giving 
the food frequently and in small quantity at a time. When breast milk 
is available, it should be pumped from the breast and given every hour 
or two. Or, for the first thirty-six hours after the birth, a 5 per cent, 
solution of milk-sugar, or freshly prepared whey, made from cow's milk 
by coagulating it with rennet and straining through muslin, as directed 
under Artificial Feeding, may be given. When breast milk is not 
available, whey may be exclusively given for the first week, and then it 
may be mixed with a little rich top milk, beginning with one-fourth rich 
milk, and gradually increasing this to one-third. When the child refuses 
to take sufficient food, as is frequently the case, gavage should be resorted 
to. A half-ounce of breast milk may be given every two hours to a 
seven months' child, and three-fourths of an ounce to an eight months' 
child. 

The usual period of incubation is from one to three months, but must 
be subject to the judgment of the physician in the individual case. It will 
depend upon the circulation of the infant and upon its power to main- 
tain its own body heat. When it is desired to discontinue the use of 
artificial heat, it is well to first gradually reduce the temperature of the 
incubator, day by day, to that of the room. It will usually be unsafe to 
dispense with the incubator until the child begins to gain weight and is 
able to nurse at the breasts or the bottle. 

In many cases it will be advisable to keep the infant in the incubator 
until the period of full term has arrived. This, however, is not always 
necessary. 

The habit of nursing may be cultivated by feeding through a nipple- 
shield. 



PLATE XIX. 




tz^ 



Uterus with Two-egg Twins. (After Smellie.) 



PART Y. 

PATHOLOGY OF PREGNANCY. 



CHAPTER XII. 

MULTIPLE PBEGNANCY. 

By multiple pregnancy is meant the development of two or more 
embryos within the maternal organism at the same time. While, as a rnle, 
this takes place within the uterine cavity (Plate XIX.), numerous cases 
are on record in which one embryo has found lodgement within the womb 
and another outside of it, combining uterine and extra-uterine gestation. 

The reason for the occurrence of multiple fcetation is not known, but 
speculation has given rise to many theories, the most plausible of which 
is that the condition is one of atavic manifestation. In its etiology the 
influence of heredity, especially on the mother's side, is well established, 
but instances of a paternal bias are not wanting. Conditions, such as 
climate, environment, and the like, appear to have little effect in deter- 
mining plural conception, yet in certain localities plural pregnancies 
occur with much greater frequency than in others. 

Kumpe found that in twenty-nine cases of single-egg twins the mothers 
were under twenty-five years of age in 70 per cent., and in one hundred 
cases of two-egg twins the mothers were between twenty-six and thirty 
in 50 per cent. 

Frequency. Twin conception is more frequent in women who have 
already borne children, and more so in old than in young prim i gravida?. 
Of multiple pregnancies the commonest variety is twins ; triplets more 
rarely occur. Quadruplets, and even quintuplets, are met with excep- 
tionally. Keported instances of a larger number of embryos developed 
simultaneously in the same woman have not been sufficiently authentic 
to merit credence. According to G. Veit, in 13,000,000 births, twins 
occurred once in 89, triplets once in 7910, and quadruplets once in 
371,126 labors. For this country these figures maybe accepted as ap- 
proximately correct, though recent statistics from two of the largest 
Eastern cities place the proportion of twins at one in every 120 labors, 
while Green found three cases of triplets among 5626 labors (one in 
1875) in the records of the Boston Lying-in Hospital. 

Mode of Origin. Twins may arise (1) from a single ovum, the germ 
dividing, (2) from two separate ova developing in the same Graafian fol- 
licle — rarely, 1 (3) from two ova extruded from different portions of the 

1 While in the ovaries of the new-born child, and especially of the unripe foetus, a Graafian follicle 
is sometimes seen to contain two, three, or even four ova (Pantellani), Waldeyer states that in the 
adult human ovary he has never found more than a single ovum in a follicle. 

( 290 ) 



300 PATHOLOGY OF PREGNANCY. 

same ovary, or (4) from two ova each proceeding from a different ovary. 
Triplets arise from three distinct ova, or from one-egg twins and a single 
ovum, while quadruplets come from double twins, or from twins and 
two single ova. 

Of twins those developing from two distinct ova are the most frequent, 
and the combined average weight of such children is greater than in the 
case of single-egg twins, while the difference in weight of the individual 
gemellus is more marked in the latter instance. This is probably due 
either to nutritive causes or to the inherent weakness of a divided germ. 

Sex of Twins. Veit found that of 150,000 twin pregnancies in rather 
more than one-third both children were males, in less than one-third both 
were females, and in the remaining third both sexes occurred. The 
more recent statistics of Eumpe show that of 65 single-egg twins, both 
children were males in 36, and both females in 29, and of 101 two-egg 
twins, in 31 both were males, in 16 both were females, and in 54 each sex 
was represented. This indicates that in about Q6 per cent, of twins both 
children are of the same sex, with the proportion of males largely in excess. 

Arrangement of Membranes. The arrangement of the membranes in 
twin conceptions depends upon the origin of the embryos. The decidua 
vera is always single ; the reflexa is single for one-egg twins, and double 
when two ova become attached at different portions of the uterine sur- 
face. 1 The chorion is, also, always single when two embryos develop from 
the same egg, and double when two ova are involved. The amnion, an 
individual product, is probably always primarily double. Where two 
embryos occupy a common amniotic sac, the median wall, which originally 
separated them, may undergo absorption, but careful search will gen- 
erally reveal some vestige of its former presence. 

The Placenta. As the embryonic portion of this organ is always of 
individual origin, it follows that in all cases of twin pregnancy the 
placenta is at first double. But the close proximity of the two structures 
in one-egg twins usually leads to fusion of their contiguous edges, with 
subsequent deep and superficial anastomoses of the bloodvessels ; while in 
two-egg twins, although a widely distant implantation of the placenta? may 
result in their permanent separation, very frequently their borders will 
be found to have become united, with an easily recognizable intermediate 
zone lying between. Whenever two chorions are developed anastomosis 
of the placental vessels does not take place. Placentae succenturlatoe 
(separate or accessory lobes) occur with frequency in twin pregnancies, 
as well as anomalies in the insertion of the placental end of the cord. 

The individual growth of twin embryos varies greatly, according to 
the proportion of blood supply furnished to each. Any interference 
with the circulation in the one — whether resulting from imperfect attach- 
ment, early partial separation from accidents to the placenta, anastomotic 
complications in joined placentas, inherent feebleness of the embryo, dis- 
orders of the membranes or the like — immediately acts to the advantage 
of the other; the latter, by its more rapid development and augmented 
strength, the expansion of its envelopes and increase of the surrounding 
liquor, soon acquires such supremacy over its fellow that this eventually 
perishes, and is either compressed and flattened against the uterine wall 
as a foetus papyraceus, degenerates into a mole, or is prematurely cast 
1 A single reflexa mav exist where two ova are situated verv near together. 



MULTIPLE PREGNANCY. 301 

off from the uterine cavity; the fortunate individual, on the other hand, 
continues to advance to the completion of gestation. It is estimated that 
the intra-uterine death of one embryo occurs with three times greater 
frequency in one-egg twins than in those developed from two separate 
ova, a circumstance readily accounted for by the fact that malformations 
and pathological conditions are much oftener met with in the former than 
in the latter. 

Sup erf (station. In rare instances it has happened that the atrophied 
body of the dead foetus has been retained in utero for a considerable time 
after the expulsion of the living child at term. Occasionally, instead of 
perishing, the growth of the feebler embryo may be retarded only by the 
more rapid and vigorous advancement of the brother, and, after the 
delivery of the latter, may continue its intra-uterine existence for a period 
of weeks or even months until its development is completed. The fact of 
such a delivery following at an indefinite interval after the expulsion of 
the first child has led to belief in the possibility of su perforation as 
opposed to superfecundation. 

Superfecundation. By the latter term is understood the fertilization of 
more than one ovum, discharged at the same ovulation, by separate acts 
of insemination at short intervals, while superfoetation implies the im- 
pregnation of an ovum daring such time as another ovum from a pre- 
vious ovulation is in process of utero-gestation. While superfoetation 
is theoretically possible, it has not been proved. 

Pathological Character. Possibly owing to the excessive distention of 
the uterus as much as to other causes — hydramnios being a frequent 
accompaniment — there exists a marked tendency in plural pregnancies 
to an early termination of gestation, and miscarriage and premature 
delivery are particularly liable to result in cases of one-egg twins, quad- 
ruplets, and quintuplets. 

Both children in twin pregnancies may be expelled at the same labor, 
or at intervals ranging from eighteen to twenty-four hours, or even longer, 
as already mentioned. The offspring of plural pregnancies are often of 
feeble vitality, and one child is quite likely to succumb within a com- 
paratively short time following delivery. Monstrosities are much more 
liable to be developed under these conditions, and the mothers are more 
prone to eclamptic attacks than when the pregnancy is simple. 

Diagnosis of Multiple Pregnancy. 

The existence of twin pregnancy may, as a rule, be determined with 
reasonable certainty by the following data : (a) Excessive size and ten- 
sion of the abdomen are significant of twins. (6) Permanent uterine 
tension with very limited mobility should suggest multiple foetation. 
Persistent tension is present in simple hydramnios, but here there is pre- 
ternatural mobility of the foetus. It also occurs in the concealed form 
of accidental hemorrhage, but the latter condition is distinguished by 
its shorter duration and by the signs of internal hemorrhage, (c) The 
abdominal tumor is usually broader than in single foetation. Some- 
times the abdomen presents a sulcus corresponding to the space be- 
tween the two foetuses; but this may arise from other causes. (d) 
Detection by abdominal palpation of two foetal heads, or of two dorsal 



302 PATHOLOGY OF PREGNANCY. 

planes, of three or four foetal poles, or of a multitude of small parts is 
usually possible, (e) Detection of one head in the excavation and one 
in the upper uterine segment makes the diagnosis of twins. (/) One 
head may be found in the excavation and one in an iliac fossa, (g) Dis- 
tance from pelvic pole to fundal pole more than 30.5 cm., 12 inches, is 
evidence of twins, {h) The recognition, by auscultation, of two foetal 
heart-sounds, not synchronous, and heard at different locations, is con- 
elusive. It must not be forgotten, however, that one foetus may be 
dead. Even when both are living the detection of two independent 
heart-sounds is frequently impossible, (i) Suprapubic oedema is almost 
invariably present in plural pregnancy. This, however, may occur in 
single pregnancy with hydramnios, since it arises from venous stasis in 
the abdominal wall due to pressure brought about by the greatly dis- 
tended uterus. 

Vaginal Signs. During pregnancy twin foetation presents practically 
no characteristic signs obtainable by the vaginal examination. In course 
of the labor one or more of the following conditions may be detected, 
(a) Rapidly successive presentation of a head and a breech, (b) Four 
extremities presenting, (c) Two amniotic bags offering at the cervix. 

The diagnosis of triplets is sometimes possible after the pregnancy has 
reached the later months. In quadruple pregnancy the existence of mul- 
tiple foetation should be capable of recognition, but the number of chil- 
dren can scarcely be determined before birth. 

Management of the Labor. The usual risks of labor for both mother 
and child are somewhat increased in twin births. The labor is fre- 
quently longer and is more likely to be complicated than in single foeta- 
tion. Owing to overdistention, the uterus may retract less promptly in 
the third stage, and the danger of post-partum hemorrhage is greater. 
The viability of the child is less than in normal gestation. In nearly 25 
per cent, of cases the labor is premature. These facts must be borne 
in mind in the management of the labor and the after-care of the 
children. 

According to the statistics of Klein wachter and of Speigelberg, in 50 
per cent, or more of twin births both foetuses present by the vertex. 
Breech and transverse presentations are more common than in ordinary 
labors. 

When the first child is larger than the second, the second birth, as a 
rule, is rapid. The delivery of the second foetus is rarely delayed more 
than a few hours. The cord of the first child should be ligated on the 
maternal as well as the foetal side, owing to the possibility of communi- 
cation between the placental circulations. The membranes of the second 
foetus may be ruptured as soon as labor pains are resumed after expulsion 
of the first. 

Interference in either delivery must be governed by the same rules as 
in single births. 

Both placentas are usually expelled together after the birth of the 
second child. Very rarely, when the placentas are entirely distinct, the 
first one may come away before the expulsion of the second foetus. 

Special care will usually be required by manipulation and the use of 
ergot to secure full retraction of the uterus. 

In triple births the management is, in general, the same as in twins. 



CHAPTEE XIII. 

ANOMALIES AND DISEASES OF THE FCETAL APPENDAGES. 

Diseases of the Decidua. 

Inflammation of the Decidual Tissues. As the decidua is merely the 
hvpertrophied and modified mucous membrane of the uterus, Ave find it 
the seat of the same inflammatory processes as occur in the endometrium 
of the non-pregnant. Decidual endometritis may be either acute or 
chronic. 

Acute Decidual Endometritis. This form of the disease is much less 
commonly met with than the chronic, and may be associated with some 
acute infectious disorder, as variola ; or it may be the consequence of 
unskilled attempts at inducing abortion. The pathologic features are 
swelling, congestion, and infiltration of the tissues with leucocytes : the 
course of the pregnancy usually is cut short by the disease. 

Chronic Decidual Endometritis. The causes given for this affection 
are a pre-existing endometritis, especially of syphilitic or gonorrhoeal 
origin, and death of the foetus with retention of the ovum ; but there are 
many cases in which no satisfactory explanation can be offered. Three 
types of the affection are described : 

A. Chronic 'Diffuse Decidual Endometritis. This form is characterized 
by a general hyperplasia, so that the decidua becomes enormously thick- 
ened : there is an increase in the amount of connective tissue and sub- 
jacent muscular fibres, together with proliferation of the decidual cells. 
The vessels are enlarged and extravasations of blood are numerous. 
If the disease develops early in pregnancy, abortion is the usual result ; 
but when the process pursues a slow course and is not pronounced, 
the term of gestation may be completed. In such a case there may, 
however, be difficulty in the separation of the membranes at labor ; 
the placenta may be adherent and require manual extraction, or some 
thickened portion of the decidua may remain in utero and give rise to 
septic trouble. 

B. Chronic Polypoid Decidual Endometritis. This type is the result 
of an uneven distribution of the hyperplastic tissue, so that excrescences, 
rounded or polypoid, are produced. This form of the disease usually 
occurs early in pregnancy, with the result of destroying the foetus and 
bringing on abortion. 

C. Catarrhal Decidual Endometritis. In this variety the prominent 
features are the involvement of the glandular tissues and a hypersecretion 
of watery mucus. If associated interstitial changes block the outlet 
of the glands, cysts may be formed ; but usually the secretion escapes 
from the uterus, and gives rise to a symptom known as hydrorrhcea 
gravidarum. 

303 



304 PATHOLOGY OF PEEGXAXCY 



Hydrorrhoea Gravidarum. The discharge from the uterus may 
vary in amount from a few drops to a pint, and occur at irregular 
intervals. The secretion finds its way between the membranes to the 
os, and escapes almost continuously, provided there be no obstruction. 
If there be adhesions between the chorion and decidua, the fluid may 
accumulate until the pressure becomes great enough to overcome the 
resistance, when it escapes in a profuse gush. Hydrorrhoea may be 
present from the early weeks of pregnancy, but usually it is a symp- 
tom not marked until the late months. The fluid is clear, slightly 
viscid, and contains albumin : spots upon the clothing frequently show a 
pinkish tinge at the margin. In diagnosing this aifection it must be 
remembered that certain non-gravid conditions, as cancer and fibroid, may 
produce a watery discharge; and when there is no doubt about the exist- 
ence of pregnancy we should be sure that the fluid comes from the uterus, 
and is not the remains of vaginal douches or the result of incontinence 
of urine. WTien the source is clearly the pregnant uterus it may be 
difficult to decide whether the fluid comes from diseased glands or from 
the amniotic sac through a small opening high on one side. Rupture of 
the membranes is diagnosed by finding that the fluid contains urea and 
flakes of vernix caseosa ; its escape does not continue over a long period 
of time, but is followed by abortion or premature labor. 

Prognosis and Treatment. Hydrorrhoea deciduale may produce 
no untoward results for either mother or child ; in a few cases uterine 
contractions appear, and probably are the result of the endometritis of 
which the discharge is a symptom. Rest and uterine sedatives are the 
only treatment which seems to be effective, although in a few cases 
potassic iodide has been favorably mentioned. 

Atrophy of the Decidua. This is a rare condition described by a few 
writers. Its result is that the ovular attachments are so imperfect that 
the ovum hangs down in the uterus and may come to lie in the cervix. 
Foetal death and abortion are the usual terminations. 

Anomalies and Diseases of the Amnion. 

Because we are still ignorant of the sources of the liquor amnii as a 
physiologic secretion but little is known of the causes which produce 
variations in the amount. Many modern authors consider this fluid of 
purely foetal origin, coming from the kidneys and skin, as well as tran- 
suding from the vessels in the cord. Other writers believe the maternal 
organism aids in its production, there being a transudation through the 
chorion and amnion from the blood-current of the mother. Probably 
both mother and foetus contribute to its production. The normal quan- 
tity at term is estimated at one or two pints. 

Oligohydramnios, or Deficiency of Amniotic Fluid. The causes of this 
condition are unknown, but the results may be pronounced. The foetal 
parts are apt to come in contact with one another and with the inner sur- 
face of the amnion ; foetal movements are therefore restrained, or they 
may result in the formation of ulcers from friction. If the uterus is 
closely applied to the body of the foetus, adhesions may form between 
it> surface and the amnion ; this relation tends to the production of 
deformities and the development of amniotic bands, a condition to be 



ANOMALIES AXD DISEASES OF THE FCETAL APPENDAGES. 305 

described later. Ballottement is impossible, and it is difficult to map 
out the foetus by palpation : the first stage of labor is slow, owing to the 
deficient bag of waters. Oligohydramnios seldom can be diagnosed, and 
is beyond the reach of treatment. 

Hydramnios, Polyhydramnios. This condition is characterized by an 
excess of liquor amnii, and often is spoken of as a dropsy of the amniotic 
sac. The minor degrees of increase are apt to be unnoticed, and we do 
not use the term hydramnios until the fluid is large enough in amount 
to produce symptoms. Statistics as to the frequency of this affection are 
unreliable from the fact that some patients are more tolerant of distention 
than others; multipara?, for instance, would be less likely to complain 
than primiparae. The marked forms of the disease probably do not occur 
often er than once in 150 or 200 confinements. In extreme cases the 
accumulation of fluid may amount to five or six gallons. 

Etiology. Uncertainty as to the sources of the liquor amnii has led 
to the promulgation of many theories concerning the causes of hydram- 
nios ; we shall mention some of the leading ones. 

A. Foetus. 1. Number. Hydramnios is frequently found associated 
with twin pregnancies, and the cause is supposed to be the relation of 
the vessels in the common placenta. If the vessels of one twin take a 
shorter course, more blood would go to that foetus than to the other. The 
result is more rapid growth and a larger, more powerful heart. Thus, 
one child absorbs more fluid from the placenta and produces excessive 
secretion, certainly from the kidneys and possibly from the skin. The 
accumulated discharges cause the hydramnios. In other cases one twin 
may exert pressure upon the other in such a way that there are stasis in 
the vessels of the cord and increased transudation through their walls. 

2. Malformations. These often are associated with hydramnios, but 
it is impossible to say Avhether as cause or effect. 

3. Health of Foetus. Syphilis seems to be a cause in some cases, espe- 
cially any syphilitic affection of the liver which raises the blood-pressure 
in the umbilical vein and leads to increased transudation. The foetus 
may be dead and macerated, but this condition may be the result of the 
hydramnios. It is only fair to say that in 100 cases of hydramnios 
Bar found 44 per cent, of the children to be in good condition. 

B. Foetal Appendages. When the accumulation is very rapid an in- 
flammation of the amnion has been suggested as an explanation. Such 
conditions as twisting and other anomalies of the cord raise the blood- 
pressure in the vein and seem to account for some of the cases. Diseases 
of the placenta and decidua should be mentioned under this head. 

C. Mother. Syphilis, albuminuria, and cardiac disease are given 
among the maternal conditions producing hydramnios. It is said that 
there are cases in which excess of liquor amnii is associated with serous 
effusion elsewhere. Hydramnion is almost twice as frequent in mul- 
tipara as in primiparse. 

Symptoms. The symptoms may be present from the beginning, but 
usually do not appear before the fifth month. The disease may take a 
chronic or an acute course. 

The Chronic Form. This is the type more frequently seen : the 
enlargement of the uterus produces (1) reflex disturbances, (2) pressure- 
effects, and (3) certain alterations in the signs of pregnancy. 

20 



306 PATHOLOGY OF PREGNANCY. 

1. Reflex Disturbances. Nausea and vomiting may be early symp- 
toms, and result in emaciation and weakness from want of nourish- 
ment. 

2. Pressure-effects. The patient has a feeling of distention which 
often amounts to severe suffering ; the pains sometimes are intermittent 
like labor-pains : there may be marked oedema of the lower extremities 
quite early in the course of the pregnancy, so that locomotion becomes 
difficult ; even in the sixth month pressure upon the diaphragm may 
cause dyspnoea and palpitation ; there may be albuminuria and jaundice. 
All those phenomena of pregnancy which we ascribe to increase of intra- 
abdominal pressure are much intensified and appear early. 

3. Alterations in the Signs of Pregnancy. On abdominal palpation 
the fundus is found at a much higher level than corresponds with the 
period of gestation ; the uterine walls seem unnaturally thin and in a 
state of permanent tension ; fluctuation may be obtained earlier than is 
usual, and is more pronounced than in normal cases ; the foetal parts can 
seldom be differentiated, but if the child can be felt ballottement is ab- 
normally marked. On auscultation the foetal heart-sounds are muffled 
or unheard. On vaginal examination the motility of the foetus is 
excessive ; the lower segment is greatly stretched and the cervix 
partially effaced and somewhat open, as if the first stage of labor had 
begun ; but the lips of the cervix are not so tense and thinned as in 
labor. Malpresentations are not uncommon, and the labor is apt to be 
premature. 

The Acute Form. In this form the excessive accumulation may take 
place in the course of a few days and rapid distention cause great suffer- 
ing : in some cases a rise of temperature occurs. There is so much 
sensitiveness of the abdomen that without an anaesthetic palpation fre- 
quently is impossible. 

Diagnosis. When there is a history of irregular menstruation and 
the small size of the foetus or thick abdominal walls render palpation 
difficult, the existence of pregnancy may be overlooked, so that hydramnios 
may be mistaken for ascites or ovarian cyst. In ascites the surface of the 
abdomen is flattened ; the flanks bulge and are dull on percussion ; there 
is resonance over the central part of the abdomen; a change in the 
woman's position alters the relation between the dull and resonant areas. 
Both hydramnios and cyst present signs quite the reverse of those just 
mentioned. If, by placing the hands over the tumor, there are felt 
alternating contractions and relaxations (Braxton Hicks's sign), we can 
exclude ovarian cyst and be quite certain that we are dealing with the 
distended uterus : when these signs are wanting we may be obliged to 
introduce the finger into the cervix as far as the internal os and feel for 
the bulging membranes. In acute cases the symptoms of hydramnios 
closely resemble those of ovarian cyst with torsion of the pedicle, and it 
may be necessary to dilate the uterus, or even to perform abdominal sec- 
tion before a diagnosis is established. 

Having established a diagnosis of pregnancy, we must distinguish an 
acute hydramnion from ectopic gestation, or be certain that the distention 
of the abdomen does not come from some associated condition. Ectopic 
pregnancy is distinguished by the cardinal signs of pain, irregular flowing, 
and the presence of a tumor beside the enlarged uterus. In pregnancy 



ANOMALIES AND DISEASES OF THE FCETAL APPENDAGES. 307 

complicated by ovarian cyst a thorough examination will result in the 
discovery of a second tumor. 

In the light of the positive evidences of pregnancy we must decide 
whether the distention of the abdomen is due to hydramnios, twins, or 
hydatidiform mole. In twins the foetal parts are easy to palpate and 
their multiplicity is evident ; there are two separate areas over which the 
heart-sounds are heard ; fluctuation is not a feature nor is ballottement 
marked. Hydatidiform mole is characterized by a peculiar discharge from 
the uterus, and will be described later. 

Prognosis. The prognosis for the child is poor, as in many cases the 
foetus is diseased ; and even when the child is healthy the frequency of 
premature labor diminishes its chances of living. The degree and 
rapidity of distention affect the prognosis, which, of course, is worse in 
the acute form, in many chronic cases there being nothing more than 
discomfort. The prognosis for the mother is less favorable than in normal 
cases, because the overdistention may permit malpositions requiring 
operative interference, and the stretched muscular fibres may not contract 
well in the third stage, thus making post-partum hemorrhage a decided 
danger. There also are risks incident to abortion and premature labor, 
such as infection and subinvolution. The increased pressure on the 
abdominal organs predisposes to toxaemia with all its resulting evils. 

Treatment. Medical treatment is of little value, except the anti- 
syphilitic in a few cases : a milk-diet is recommended for its diuretic 
action. In some cases an abdominal bandage gives relief. Whenever 
possible the case should be carried along until the foetus has reached 
a viable age, the patient being under the constant supervision of a 
physician, who must make frequent urinary examinations and adopt 
prophylactic measures against toxaemia. Labor should be induced in 
acute cases, and in those chronic ones in which there is danger from the 
excessive distention. After puncture of the membranes the fingers should 
partially plug the vagina to prevent the too rapid escape of the waters, 
and thus avoid malpresentation and syncope. When the overdistention 
prevents the proper action of the uterine fibres the membranes should be 
ruptured at the beginning instead of at the end of the first stage ; the 
time selected for the puncture should be between the pains. The second 
stage of labor may be marked by violent contractions, and the third by 
muscular atony, so that all the preparations for the control of post-partum 
hemorrhage should be made in advance. 

Alterations in the Character of the Amniotic Fluid. The appear- 
ance of the liquor amnii varies with the period of pregnancy : in 
the early months it is clear and transparent, alkaline in reaction, 
and with a specific gravity of about 100.6. Later, the fluid be- 
comes somewhat thicker and whitish from the addition of epithelial 
cells and flakes of vernix caseosa ; the liquid also contains small hairs 
from the surface of the foetal body and shows traces of urea. Sub- 
stances injected into the maternal circulation may reach the liquor amnii, 
and in cases of poisoning by the mineral salts their traces have appeared 
in the amniotic fluid. At term more or less meconium may be mixed 
with the fluid, giving it a dark-brown or greenish tinge. The death and 
maceration of the foetus may give a pinkish coloration to the liquor, or 
it may become thick and dark, with a fetid odor. Infection of the amni- 



308 PATHOLOGY OF PREGNANCY. 

otic sac may cause putrid decomposition of its contents, and may come 
about in either of two ways : there may be a small rupture of the mem- 
branes, high up at one side, where micro-organisms may enter, but 
through which the sac cannot entirely empty itself; or a severe and long- 
continued infective disease of the mother may lead to infection of the 
foetus and subsequently to that of the amnial liquor. 

Amniotic Bands. These probably are the result of adhesions between 
foetus and amnion, being particularly favored by deficiency of the liquor 
amnii ; later, the distention of the uterine walls draws out the adhesions 
into bands which may be simple or branching. Sometimes the bands 
rupture during this process, and one end is found floating free while the 
other is attached to either skin or amnion. Either the adhesions or the 
bands may make so much traction upon that portion of the child to which 
they are attached that deformities and the death of the foetus result : pre- 
mature detachment of the placenta may be caused by the pulling of short 
bands. In some cases the bands encircle a limb and produce amputa- 
tion, an injury which has been wrongly ascribed to the action of a coil 
formed from the umbilical cord. 

Diseases of the Chorion. 

Myxomatous Degeneration of the Chorion. This disease is commonly 
known as hydatidiform or vesicular mole, and is rather rare, occurring 
about once in one or two thousand cases. The affection consists of 
proliferative degeneration of the chorionic villi, resulting in the forma- 
tion of cysts, most of which vary in size from that of a millet-seed to 
that of a grape, although a few reach the size of hens' eggs. The pedi- 
cles of these cysts consist of the trunks and branches of the villi, so that 
the arrangement suggests that of a bunch of grapes. (Plate XX.) On close 
examination, however, it may be seen that some cysts spring from the walls 
of others and that there are several on a single stem, the intermediate 
constricted portions often being patulous, so that fluid can be forced from 
one cyst to the next. The vesicles themselves are rounded, fusiform, or 
pyriform, and are distended with a clear, yellowish or pinkish fluid of 
watery consistency and containing albumin and mucin. 

In some cases the aggregation of cysts may form a mass as large as a 
child's head and be covered and infiltrated with blood-clots. A smaller 
neoplasm may be expelled wrapped in a decidual layer, which must be 
incised before the cysts appear. On laying open a vesicular mass all 
traces of foetus and amniotic sac may be wanting, or there may be a col- 
lection of gelatinous fluid in which only the remains of a foetus or um- 
bilical cord are found. In other cases, particularly when all the villi are 
not affected, the foetus may be present, its development corresponding to 
the period of pregnancy at which its death occurred. 

Pathology. "When the entire chorion is involved the disease is 
classed as complete, and such is the usual form when the degeneration 
begins early in pregnancy. If the affection does not begin until there has 
been some atrophy of the villi, we have the partial variety, which usually 
is confined to the neighborhood of the placental site. The extent of the 
chorion involved determines the fate of the child, there being cases in 
which only a few cotyledons of the placenta are diseased and the child's 
health unaffected. 



PLATE XX. 




VESICULAR MOLE 



ANOMALIES AND DISEASES GF THE FOETAL APPENDAGES. 309 

There is some discussion as to the pathologic role played by the different 
tissues of the villus. A normal villus consists of a stroma made up of 
mucoid tissue continuous with that in the umbilical cord ; upon this are 
two layers of cells, of which the outer comes in contact with the decidua, 
and is known as the syncytium. Virchow considers hydatidiform mole 
to be the result of hypertrophy and degeneration taking place in the 
stroma of the villus, i. e., it is a myxoma of the chorion. While the 
majority of writers seem to agree with Virchow, several recent French 
and German observers have called attention to changes in the cell-layers, 
and throw considerable light upon the mode of behavior of certain of 
these neoplasms. L. Ouvry states that there are marked proliferation 
and degeneration of the cellular layers, so that upon the walls of the 
larger cysts may be seen bud-like outgrowths made up of the elements 
of the syncytium and deeper layer ; where the vesicles come in contact 
with the uterine walls these processes are more pronounced than in the 
depths of the neoplasm. There are other investigators who go so far as 
to say that the morbid processes are confined to the cellular coverings of 
the villi. 

Vesicular Jlole and Jfalignancy. In most instances the mass of degen- 
erated villi is limited by the decidua and uterine wall, but, even in small 
moles, it is not uncommon to observe that the decidual envelope has been 
thinned in spots by invasion of the vesicles. Cases have been reported 
in which the muscular tissue of the uterus was eroded and large vessels 
penetrated, so that fatal hemorrhage followed removal of the mole ; 
also uterine rupture and fatal peritonitis have been known to be pro- 
duced by the presence of the neoplasm. It is pretty generally admitted 
that deciduoma malignum springs from syncytial cells remaining in utero, 
and hydatidiform mole is now recognized as one of the most potent 
predisposing causes. Veit maintains that there is some unknown patho- 
logic condition connected with pregnancy underlying both vesicular mole 
and deciduoma malignum. Thus, there seem to be both benign and 
malignant moles, and the majority of the cases of deciduoma malignum 
have a previous history of vesicular mole. 

Etiology. The causes of vesicular mole are not known ; both a 
foetal and a maternal origin have been suggested, but the weight of 
authority at present seems to incline toward favoring a maternal causation, 
considering the death of the foetus as secondary. Syphilis and tuberculosis 
are mentioned among the predisposing causes. Virchow considers the 
primary factor to be disease of the decidua. In most cases the mother 
is a multipara and over thirty years of age. 

Symptoms. The symptoms usually show themselves before the tenth 
week, and, associated w T ith the evidences of pregnancy, there may be the 
following signs : 

A. Bloody Discharge from the Uterus. This is the most common 
sign, being present in two-thirds of all the cases. The hemorrhage ap- 
pears without warning, and is frequently repeated : each attack of flow- 
ing usually is followed by a pinkish, watery discharge of fetid odor. 

B. Disproportionate Size of the Uterus. When the disease is of the 
complete variety the uterus may be much larger than corresponds with 
the period of pregnancy; but although the uterus may be as large as at 
the fifth or sixth month, no evidence of the presence of a foetus can be 



310 PATHOLOGY OF PREGNANCY. 

obtained either by palpation or auscultation. The increase in size may 
be rapid, and the uterus then remain stationary, owing to the death of 
the fetus ; when the degeneration is partial there may be no increase of 
size. 

C. Change in the Physical Characteristics of the Uterus. In well- 
marked cases the uterus may have a doughy feel, and occasionally its 
outline is irregular. 

D. Discharge of Vesicles. This is a pathognomonic sign, but, unfor- 
tunately, rarely is present until the process of expulsion has begun. 

The almost constant drain from the uterus produces marked anaemia 
and debility; pressure may cause hepatic and renal insufficiency, and 
there may be considerable abdominal pain. Frequently the general 
aspect of the patient suggests the presence of malignant disease. 

Prognosis. — For the child the outlook is very dark, both on account 
of impairment of nutrition and its early expulsion ; it is very rare for a 
large mole to be retained beyond the sixth month. There are several 
instances recorded in which, in a twin pregnancy, only one chorion was 
affected and one child was delivered viable. For the mother the dangers 
are hemorrhage and infection, as well as the possibility of uterine rupture 
or subsequent malignant disease. In some cases portions of the mole 
have remained within the uterus during many months, giving rise to re- 
peated hemorrhages, and rendering the patient liable to septic infection. 
When the disease is so slight that the health of neither mother nor 
foetus is affected the question of prognosis does not come up, as the 
diagnosis is not even suspected. 

Diagnosis. — Until the stage of expulsion the diagnosis of hydatidiform 
mole may be extremely difficult, owing to the absence of signs of preg- 
nancy. The enlarged uterus, together with irregular flowing and a 
cachectic appearance, suggests the presence of an intra-uterine tumor ; 
this is particularly the case when the symptoms develop near the period 
of the menopause. Exploration of the uterus may be necessary before 
the diagnosis can be made. If the diagnosis of pregnancy is clear, 
hydatidiform mole must be distinguished from hydramnion, twins, and 
normal pregnancy with symptoms of threatened abortion. In hydram- 
nion the symptoms do not belong to the early periods of pregnancy, and 
fluctuation or ballottement may be obtained, although it must be re- 
membered that in both affections all evidences from the foetus may be 
wanting. Twin pregnancy has nothing in common with vesicular mole 
except the uterine enlargement; as abortion is common in cases of 
mole, only the progress of events will show the condition of the ovum, 
unless through the dilated cervix some of the cysts may be felt. More 
Madden states that before the fourth month it is usually impossible to 
differentiate myxomatous degeneration of the chorion from a normal 
pregnancy. 

Treatment. — When the diagnosis is established the indication is to 
empty the uterus at once, for the chances of saving the child are so ex- 
tremely small that it is unjustifiable to expose the mother to further risk. 
The cervix may be dilated with steel dilators or the Barnes bags, and 
then the finger, aided by the long-handled abortion forceps, shoulol be 
used for the removal of the neoplasm. In some cases the entire hand 
is introduced within the uterus, but the danger of rupturing a thin wall 



ANOMALIES AND DISEASES OF THE FCETAL APPENDAGES. 311 

must be remembered, and all intra-uterine manipulation must be gentle. 
It is a good plan to make counterpressure over the abdomen while 
working within the uterus. As the great danger is hemorrhage, which 
cannot be controlled until the uterus is firmly retracted, the cysts must 
be cleared out rapidly, followed by the use of hot irrigations and hypo- 
dermatic injections of ergot. The curette is a dangerous instrument, as it 
may readily perforate the uterine tissues ; but its use is sometimes neces- 
sary when the cysts are imbedded in the decidua, for thorough removal 
undoubtedly diminishes the risk of subsequent deciduoma malignum. 
The liability to septic infection calls for strict asepsis, during the abor- 
tion as well as afterward. 

Anomalies of the Placenta. 

At the end of pregnancy the placenta is an oval-shaped mass measur- 
ing two to three centimetres in thickness at the site of the insertion of 
the cord, and having a diameter of from sixteen to eighteen centimetres 
across its widest portion ; its weight is about one pound. 

Anomalies of Size. The thickness of the placenta generally is in- 
versely proportionate to its extent. In rare instances a thin placenta 
extends almost entirely around the amniotic sac, owing to a persistence 
of all the chorionic villi ; such a condition constitutes placenta membra- 
nacea. A large placenta usually accompanies a large foetus, and vice versa. 

Placenta Marginata. In this variety of placenta the membranes do 
not cover the entire foetal surface, but leave a margin which may be the 
seat of numerous blood-clots, or, later, be marked by a circular whitish 
band ; a healthy placental zone may develop just beyond this band. 
Sometimes the edge of the placenta appears as if slightly turned up ; the 
term placenta circumvattata is applied to this condition. After studying 
many specimens, G. Klein concludes that placenta marginata is the result 
of a thickening of the margin of the decidua reflexa, caused by inflam- 
mation. Placenta marginata probably dates from the beginning of preg- 
nancy and may interfere with the development of the foetus, or even 
cause abortion. J. W. Williams classes this condition under the head of 
placental infarcts, the whitish band being fibrinous and representing the 
final modification of the effused blood. 

Anomalies of Position. The normal situation of the placenta is in the 
upper segment of the uterus ; attachment extending below the level of 
the retraction ring constitutes placenta prsevia, the features of which are 
elsewhere described. 

Anomalies of Shape. Instead of being oval, the outline of the pla- 
centa may be very irregular, in rare cases even crescentic or horseshoe 
shaped. When several cotyledons are excessively developed the placenta 
is said to be multilobular. Usually the cord joins the centre of the pla- 
centa ; when it is inserted at the margin a battledore placenta results. 

Multiple Placenta. There may be two placental masses of almost 
equal size or there may be accessory placenta? consisting of only a few 
cotyledons — placentce succenturiatce. The accessory placenta? are connected 
by a bridge of membranes upon which run the vessels from the umbilical 
cord. Placentce spurice are groups of villi having no relation with the 
maternal blood-stream. Accessory placenta? have great clinical impor- 



312 PATHOLOGY OF PREGNANCY. 

tance, as a physician unknowingly may leave placental tissue within the 
uterus and expose his patient to the dangers of hemorrhage and sepsis. 
If, after the delivery of the placenta, the membranes appear torn away 
near the placental margin, they should be washed and held up to the 
light in order to see if they contain the portions of ruptured vessels run- 
ning to an accessory placenta ; the least indication calls for manual 
exploration of the uterine cavity. 

Diseases of the Placenta. 

Infarcts of the Placenta. 1 The following varieties of infarcts are 
mentioned by Williams : 

1. Small whitish areas, of slight depth, upon the foetal or maternal 
surface and sharply marked off from the surrounding placental tissue. 

2. Wedge-shaped or rounded areas seen on section of the placenta and 
presenting a whitish fibrinous appearance. 

3. One or more cotyledons, sometimes the greater portion of the organ 
converted into a pale, white, dense fibrous mass. 

4. A rim of whitish or yellowish-white material extending for a vary- 
ing distance around the margin of the foetal surface of the placenta — 
placenta marginata. 

5. Pinkish or brick-dust colored masses, solid and irregular in shape, 
of varying size, and most marked on the maternal surface. These are 
known as red infarcts. Less frequently there may be found dark-red or 
blackish areas scattered through the placenta. These blood-masses are 
separated from the placental tissue by a capsule of fibrinous material, 
and also are known as red infarcts, but more commonly are spoken of as 
apoplexy of the placenta, ; their pathology is not the same as that of the 
brick-dust colored areas. 

Frequency of Placental Infarcts. (Plate XXI.) Williams 
found that every one of the five hundred placenta? examined contained 
infarcts, although sometimes only of microscopic size : in 63 per cent, 
of the cases the infarcts measured one centimetre or more in diameter. 

Pathology. In most cases the white infarcts represent the later 
stages of the red : the pink ones owe their color to the entanglement of 
red globules within the meshes of the fibrin. On section an infarct pre- 
sents a variety of appearances. Some of the white ones show almost 
nothing but fibrin, except perhaps a few degenerated cells in the centre ; 
in others, villi may be made out, but in a more or less degenerated state. 
A few T of the white infarcts show no trace of fibrin, but are made up of 
degenerated villi pressed into a mass. 

The exact processes which produce infarcts are still subjects for discus- 
sion. Williams comes to the same conclusions as Ackermann, Eden, and 
others that the changes first take place in the vessels of the villi, and are 
in the nature of an endarteritis and periarteritis, whereby the lumen of 
the vessels is narrowed or obliterated : this produces a coagulation-necrosis 
of the cellular layers covering the villus and leads to coagulation of the 
maternal blood lying in the intervillous spaces. Steffeck, on observing 
so-called decidual cells in the centre of many infarcts, considered that the 

1 Adapted from article by J. Whitridge Williams in American Journal of Obstetrics. June, 1900, 
entitled, "The Frequency and Significance of Infarcts of the Placenta, Based upon Microscopic 
Study of Five Hundred Consecutive Placentae." 



X 



PLATE XXI. 




.'.;/ 



\ > 



PLACENTAL INFARCTION IN ECLAMPSIA 



ANOMALIES AND DISEASES OF THE FOETAL APPENDAGES. 313 

process had its beginning in excessive proliferation of the decidual cells 
which grow up about the villus and check nutrition : in the depths of the 
placenta these cells are supposed to come from the septa penetrating the 
organ from the maternal decidua. Steffeck considers that the arterial 
changes are secondary and not always present. Veit suggests endome- 
tritis as the primary cause. Williams, while not denying Steffeck's 
conclusions to be applicable to some cases, thinks that the so-called 
decidual cells are not maternal but foetal in origin. The only explanation 
offered for those infarcts which contain no fibrin is that thrombosis has 
plugged certain vessels in the maternal decidua, so that the blood is shut 
off from a limited area in the placenta ; the pressure in the surrounding 
portions compresses the villi lying in the affected region into a mass 
which soon begins to show evidences of degeneration. Nothing very 
conclusive can be said concerning the dark-red and blackish infarcts, 
except that they are the result of processes other than those mentioned. 
Owing to the fact that in many cases these infarcts appear to be sur- 
rounded by a capsule of fibrin, it has been suggested that they are the 
result of a fresh effusion of blood into a previously formed infarct ; there 
seem to be pathologic findings which warrant such a conclusion. In the 
centre of some infarcts, especially the large pink ones, there may be 
found cavities containing thick, grumous material resembling pus ; the 
presence of these cavities led the older observers to the opinion that 
placentitis was the underlying factor in the production of infarcts. 
Microscopic examination, however, shows that the material is not pus, 
but cellular debris and softened thrombus. In other infarcts the cellular 
contents may degenerate and a cavity filled with fluid be the result ; by 
this process cysts of the placenta are formed. 

Etiology. But little is known of the causes underlying infarct- 
formation in the placenta. There is no evidence of a bacterial origin, 
and they are found so often in non-syphilitic women that specific disease 
cannot be an important element. Albuminuria is given as a cause, partic- 
ularly of placental apoplexy, and there seems to be a decided relation 
between the two affections. Cagny found red infarcts in one-third of 
the albuminuric cases ; Martin noted infarcts in 47 per cent, of women 
having albumin in their urine, and in 67 per cent, of these the children 
were born dead or imperfectly developed. Exactly how albuminuria 
produces the infarcts is not known. Infarct-formation is not par- 
ticularly marked in cases of acute eclampsia, owing perhaps to the 
brief duration of the disease. Moderate degrees of infarct-formation 
are to be regarded as signs of senility of the placenta, and are anal- 
ogous to the changes taking place in the villi of the chorion at an earlier 
period. 

Effect upon Fcetxts. — The moderate degrees of infarct-formation 
have no effect upon the foetus, but extensive interference with the func- 
tion of the placenta would result in foetal death. As has been pointed 
out under Toxaemia, albuminuria is a frequent accompaniment of auto- 
intoxication, and in those cases in which the foetus dies and infarcts are 
found in the placenta it is probably the toxic state of the blood rather 
than the local condition which produces the bad result. 

Diagnosis and Treatment. — Slight infarct-formation displays no 
symptoms. If the condition leads to foetal death, symptoms of abortion 



314 PATHOLOGY OF EEEGXAXCY. 

develop. The treatment consists in relieving toxic conditions and in 
emptying the uterus after the death of the foetus is assured. 

Calcareous Degeneration of the Placenta. On passing the finger over 
the maternal surface of the placenta small sand-like bodies often may be 
felt, which consist of calcic or magnesie carbonates or phosphates. Some- 
times these grains are aggregated into needles or small plates. J. W. 
Williams states that in examining infarcts it was common to find in 
them deposits of calcareous material, so probably this degeneration usually 
is secondary to deposits of fibrin ; it is without pathologic importance. 

Fatty Degeneration. Fatty degeneration may be observed in small 
areas, particularly in those situated near the margin of the placenta. The 
causes are not known, but the degeneration probably is secondary to 
other processes, such as infarct-formation. 

Tumors of the Placenta. These are quite uncommon ; Albert collected 
all reported cases, which, together with four of his own, amounted to 
forty. The tumors consisted of myxomata, adenomata, and sarcomata. 
Diagnosis before labor usually is impossible ; a rapidly growing tumor 
might lead to expulsion of the foetus and retention of the placenta. 

Cysts. Cysts are frequently found on the foetal surface of the 
placenta in the neighborhood of the insertion of the cord ; they rarely 
are as large as pigeons' eggs. The contents may be clear and gela- 
tinous or brown and watery. Most observers consider that placental 
cysts are the result of degeneration taking place in infarcts, but Peiser 
recently has demonstrated that cysts may develop as a result of liquefac- 
tion of the cells covering the villi ; these cellular elements are quite fre- 
quently present in the centre of an infarct. 

Placentitis. By this term is meant inflammation of the placenta, 
although the organ never shows such signs as redness, swelling, and 
formation of new vessels. The main changes consist of modification 
of the connective tissue surrounding the vessels, producing a condition 
analogous to that found in the liver or kidneys of an adult. The 
placenta may become indurated and adhere firmly to the uterine wall. 
Delore speaks of a bacterial placentitis, which he ascribes to the passage 
of bacteria through the placenta to the foetus, as we know that micro- 
organisms can reach the foetus by that route ; he even divides the affec- 
tion into decidualitis and villositis according to the parts involved. The 
changes seem to be much the same as those described under Infarcts, and 
the propriety of employing a term implying inflammatory processes may 
well be questioned. 

Syphilis of the Placenta. The classic description given by Fraenkel in 
1873 still expresses most of our knowledge on this subject ; he makes 
the following statements : 

1. When the disease has been transmitted from the father the principal 
lesion is hypertrophy of the villi. 

2. When the mother is infected with syphilis the placenta is degen- 
erated and the foetus diseased ; the villi are filled with fatty granules, the 
vcsspIs are obliterated and their epithelial covering is thickened or absent. 

3. If the mother is infected during the generative act at the same time 
as the ovum, syphilitic foci will often develop in the maternal placenta. 

4. If the mother is syphilitic before conception, or becomes so shortly 
after, the placenta is syphilitic in about 50 per cent, of the cases. 



ANOMALIES AXD DISEASES OF THE FCETAL APPENDAGES. 315 

5. If the mother is not infected until after the seventh month of ges- 
tation, both foetus and placenta wholly escape. 

6. Infection of the foetus during delivery has not been proved. 
Bonet states that under the microscope various lesions are observed, 

such as hemorrhagic foci, thrombosis, white infarcts, and fatty degener- 
ation. The vessels show thickening of their walls and diminution of 
their calibre. 

Pinard, Lapage, and Schwab call attention to a marked increase in the 
weight of the placenta in proportion to the weight of the foetus. Pinard 
considers this hypertrophy to have a certain diagnostic value. 

Anomalies of the Umbilical Coed. 

The anomalies of the cord embrace variations in length and placental 
insertion, coils, knots, exaggerated torsion, stenosis of vessels, and navel- 
cord hernia. 

Length. The length of the cord averages from forty to sixty centi- 
metres, but there are instances in which the length was diminished to ten 
centimetres and increased to three metres. 

Shortness of the cord may be absolute or relative : relative shortness is 
produced by coils about the foetus, and dystocia may be the result, the 
presenting part being hindered in its descent or making rapid retrograde 
movements after each uterine contraction. During labor, if a short cord 
does not rupture, it may cause uterine inversion or detachment of the 
placenta. 

When the cord is unusually long there is a predisposition to funis 
presentation and prolapse : a loop may become caught around the foetus ; 
for instance, between the buttocks in a breech presentation, and relative 
shortness result. 

Insertion. In some cases the cord terminates in the membranes, between 
which the vessels continue their course to the placenta — insertio vela- 
mentosa. In such a relation there is danger that the vessels may be 
ruptured during labor, and unless rapid delivery follows the child's life 
be lost. 

Coils. It is common for the cord to be coiled once or twice about 
the child's neck : nine turns have been noted by Braun. When the 
coiling is sufficient to produce relative shortness of the cord there is 
danger that, during descent, a fatal strangulation of the tissues may result. 
Coiling is most dangerous Avhen the cord is about the neck in a breech 
labor, as the constriction cannot be released until late in the delivery. It 
has been suggested that a coil might be drawn tight enough around a 
limb to produce amputation, but it is probable that the cases of so-called 
spontaneous amputation are the result of constriction by amniotic bands, 
for before the cord could be made sufficiently tense to cut through the 
foetal tissues the circulation in the umbilical vessels would be shut off 
and death of the foetus take place. Coils are said to occur more frequently 
when the children are males and in multipara?. 

Knots. A knot may result if the foetus be passed through a twisted 
loop of the cord; several knots may be produced in this way, the favoring 
conditions being a long cord and excess of liquor amnii. If the knot is 
old, there may be atrophy of the jelly of Wharton at that point ; in 



316 PATHOLOGY OF PREGNANCY. 

recent cases the tissues of the cord are usually unchanged. It is not 
common for the knot to be pulled tight enough to cut off the circulation 
in the vessels, and the gelatinous material acts as an efficient protection, 
at least for a time. In twin pregnancies, when the children are in the 
same amniotic sac the two cords may become united in so firm a knot 
that the death of both children may result. 

Torsion. The cord normally displays an apparent twisting from left 
to right, and occasionally there is an actual torsion, which may be so 
extreme that the vessels are almost obliterated. Three hundred and 
eighty twists have been observed. The seat of the torsion is usually at 
the umbilicus, and very seldom at the centre of the cord or near the 
placenta. The foetus is found dead in all cases of pronounced torsion, 
and the excessive twisting is recognized as a post-mortem change, and 
not as the cause of the fatality. 

Stenosis of Vessels. In certain cords the calibre of the vein is dimin- 
ished, so that great dilatation may take place in that portion between the 
seat of constriction and the placenta ; hydramnios and oedema of the 
placenta may be the result. In cases of syphilitic infection of the foetus 
the vessels of the cord may be surrounded with a deposit of connective 
tissue. 

Navel-cord Hernia. By this is meant protrusion of some of the con- 
tents of the abdominal cavity at the point of insertion of the umbilical 
cord. It is the result of arrested embryonic development, and usually 
is associated with other deformities, such as atresia of the rectum. The 
contents of the sac are usually omentum and intestine, but any of the 
abdominal viscera may be added. 

Teeatment. During the separation of the cord a dry dressing must 
be applied with sufficient pressure to prevent protrusion of the hernia. 
While the opening is closing by granulation strict asepsis must be ob- 
served. The best treatment is the operative, and should be carried out 
immediately after birth. Under light chloroform anaesthesia the cord and 
its coverings are removed by an elliptical incision ; adhesions are separated 
and the layers of the abdominal w T all are brought together by catgut 
suture en etage ; one or two through-and-through sutures of silkworm- 
gut may be introduced first. 



CHAPTEE XIV. 

PATHOLOGY OF THE FCETUS. 

ANOMALIES. 

Uxder malformations are included all imperfect, deviating formations 
of the entire body or its parts which can be attributed to malposition in 
the uterus or deviation from normal intra-uterine development. Those 
minor deviations of development which occasion no marked change of 
form and no disturbance of function are simple anomalies. Those mal- 
formations which produce remarkable deformity of the body are monsters. 
Of these there are three great groups: 1. Monstra per defectum. 2. 
Monstra per excessum. 3. Monstra per fabricam alienam. These are 
again divided according to origin and according to outward resemblance 
into a large number of subdivisions. 

Monstra Per Defectum 

Are malformations characterized by lack of, or incomplete, development. 
1. The defect is the principal characteristic: simple anomalous formation. 

A. Absence or stunting of large sections of the body. 

1. Amorphus, Acardiacus amorphus; a formless mass covered with 

skin. 

2. Mylacephalus: Vertebra?, ribs, and pelvis present; no heart; ex- 

tremities indicated; also head, by a lump. 

3. Acephalus (Plates XXII. and XXIII.) : Abdominal portion of 

body, with one or two extremities, and various-sized portions 
of vertebrae; occasionally with upper extremities, and a rudi- 
mentary head. When present, the thorax is open anteriorly; 
the heart is always absent. Other internal organs are present 
or absent. 

4. Acormus, bodyless (Figs. 220, 221, 222). Head with imper- 

fect brain. Cord inserted in vicinity of throat. 

B. Absence or stunting of separate parts. 
a. Head. 

1. Acrania (Plates XXIV., XXV., and XXVI.) : Defective 

vertex, usually associated with anencephalus ; defective 
brain, and partial defect of the skin. The base of the skull 
is greatly shortened. Originates through superficial syne- 
chia of foetal head and amnion, or as a result of foetal hydren- 
cephalocele. Acrania is also occasionally associated with 
pseudoencephalocele. 

2. Hemicrania : Frontal, occipital, and parietal bones rudimen- 

tary. Brain rudimentary or absent ; in the latter case 
usually associated with pseudoencephalocele. 

3. Mierocephalus : Brain small in consequence of premature ossi- 

fication of skull bones. 

317 



318 



PATHOLOGY OF PREGNANCY. 



4. Cretin ism us : Too short skull base, from premature ossification 
of the synchondrosis sphenobasilaris. 



Fig. 220. 




Acardiacus acormus. (Bakkow.) 

bs. Rudiment of the left upper extremity, tr. Rudiment of intestine, a, a, a. Arteries, v. Vein. 

v. u. Umbilical vein. v. o.m. Omphalo-mesenteric vein. ur. Urachus. 



Fig. 221. 



Fig. 222. 





Acardiaci acormi. (Ahlfeld's Atlas. 



5. Cyclopia (Plates XXVII. and XXVIII.) : Both orbital fossa 
are apposed or confluent, or there is one eye which lies in one 
fossa in the median line. In the higher grades the ethmoid, 
nasal septum, and vomer are absent. The optic chiasm and 



PATHOLOGY OF THE FCETUS. 319 

tract persist or are absent. In the brain single parts, as 
convolutions, thalamus, or olfactory uerve, are wanting, or 
it terminates anteriorly as a simple bladder. 

Fig. 223. 




Hemimelus. (Hirst and Piersol.) 



6. Agnathia : Anomaly of under jaw, or absence of the lower 
jaw processes of primary blastoderm. Usually the upper jaw, 
palate, and sphenoid bones are stunted ; the ears approach 
each other, touching at their under surfaces. 



320 



PATHOLOGY OF PBEGXASCY 



7. Aprosopus : Malformation of larger or smaller portions of the 
f ace — e . g, y nose, mouth, eyelids. 
/?. Vertebral column, cord, chest. 



Fig. 224. 




Skeletou of a phocomelus. (Musee Dupuytren.) 



ATE XXII. 




Acephalus. (Hirst and Piersol.) 



PLATE XXIII 




Acephalus. (Hirst and Piersol. 



PLATE XXIV. 




Pseudeneephalus. (Hirst and Piersol.) 



PLATE XXV. 




Aneneephalus. (Hirst and Piersol 



PLATE XXVI. 




Aneneephalus. (Hirst and Piersol. 



PLATE XXVII 




Cyelocephalus. (Hirst and Piersol.) 

(Cyclops.) 



PLATE XXVIII. 




Skeleton of Cyelocephalus. (Hirst and Piersol.) 



PLATE XXIX. 



Ht 










Phocomelus. (Hirst and Piersol. 



PATHOLOGY OF THE FCETUS. 



321 



1 . Amyelie : General or partial defect of the spinal cord ; origi- 

nates from hydromyelocele. 

2. Absence of several ribs and vertebrae. 
Pelvis and extremities. 

1. Amelus : Absence of all the extremities. 

2. Peromelus : Malformation of all extremities. 

3. Phocomelus (Plate XXIX. and Fig. 224) : Hands and feet 

rest on the shoulders and hips. 

4. Micromelus: Abnormally small limbs. 

5. Abrachius: Absence of arms. 

6. Perobrachius : Defective hands and forearms on normal arms. 

7. Microbrachius : one or both arms too small. 

8. Monobrachius: Absence of one upper extremity. 

9. Sympus (Figs. 225 and 226), Syren formation: Fusion of 

lower extremities; pelvis and sacrum wanting; atresia of 
urethra and rectum. 



Fig. 225. 



Fig. 226. 





Uromelus. (Sympus monopus. Forster.) 



Strenomelus. (Sympus apus. Forster.) 



10. Apus (Fig. 227) : Lower extremities absent. 

11. Monopus (Fig. 228): One lower extremity absent. The cor- 

responding half of pelvis also absent (prolapse of intestine). 

12. Peropus: Stunted formation of one or both lower extremities. 

13. Micropus: Lower extremities small. 

d. Internal organs, intestines: The absence of entire organs is com- 
mon with malformations of head, and without a heart. It 
may occur without these anomalies. 

Absence of nose in cyclopia. 

Absence of lungs, with absence of diaphragm, and foetal hydro- 
thorax. 

Absence of lips: Acheilia. 

Absence of tongue: Aglossia, usually with agnathia. 

21 



322 



PATHOLOGY OF PREGNANCY. 
Fig. 227. Fig. 228. 





Apus. 



Monopus. 



Absence of gall-bladder; the ductus hepaticus is abnormally 
wide. 

Absence of one kidney; synchronous compensatory hypertrophy 
of the other. 

Absence of urethra, with cloaca formation. 

Absence of urinary bladder; ureters open directly into urethra. 

Absence of one or both ovaries. 

Absence of uterus. 

Absence of one or both tubes. 

Absence of external female genitals. 

Absence of vulva alone. 

Absence of hymen alone. 

Absence of one or both mammary glands, commonly with syn- 
chronous absence of ribs. 

Absence of nipples. 

Absence of prepuce. 

Absence of penis. 

Absence of one or both testicles. 

Absence of seminal vesicles. 

Absence of pericardium, with ectopia cordis. 

Partial defect is found in the brain; e. g., absence of corpus 
striatum. 

Absence of septum narium. 

Absence of inferior turbinated. 

Absence of epiglottis. 

Absence of superior segment of oesophagus, and blind ending 
of pharynx. 

Absence, partial, of trachea, with communication with oesoph- 
agus. 

Absence of tracheal cartilages, generally with abnormal fusion. 

Absence, partial, of one lung, with compensatory hypertrophy 
of the other. 

Absence of frsenum linguae, with fusion of tongue with floor 
of mouth. The frsenum may be simply too short. 



PATHOLOGY OF THE FCETUS. 323 

Absence of middle segment of oesophagus with sac-like dila- 
tation of the superior end; commonly communication with 
trachea. 

Absence of colon and rectum. 

Absence, partial, of urethra, in epispadias, hypospadias. 

Absence, partial, of hymen; hymen is cribriform, fimbriated, 
or abnormally wide. 

Absence, partial, of spermatic cord. 

Absence, partial, of prepuce, short frsenum, phimosis. 

Absence, partial, of heart. 

1. Simple muscular sac, with veins. 

2. A chamber with arteries, and auricle and primitive veins. 

3. Two auricles, one ventricle; aorta, primitive, gives off 

pulmonary veins. 

4. Two ventricles and auricles. Atresia of ostium aorticum, 

patency of septum ventriculorum and foramen ovale. 
Pulmonary artery empties into aorta. Aorta descendens 
absent. 

5. Aorta ascendens and descendens not associated ; the latter 

communicates with pulmonarv artery through ductus 
Botalli. 

6. Arteria pulmonalis narrow, closed, or absent; its branches 

communicate with aorta. 

7. Both arteries abnormally narrow; heart-cavities greatly 

dilated, septum incomplete. 

8. Situs trans versus of the aorta and pulmonary artery. 

9. Patencv of foramen ovale, ventricular septum, and ductus 

Botalli. 
10. Anomalous formation of valves; increase or diminution 
in their number. 
C. Abnormal smallness. 

1. Dwarfs (Nansomia, Microsomia): Fully developed individuals 

under 112 cm. Generally the head and trunk are of relatively 
unequal size. Occasionally all parts are in proportion. 

2. Single parts abnormally small : Heart and bloodvessels (hypo- 

plasia in chlorotics); lungs (in diaphragmatic hernia and dys- 
tocia of abdominal organs into thorax); brain (microcephalus), 
spleen, thyroid, Jips, tongue, frsenum, stomach, penis, testicles, 
toes, ears. 
II. Arrested development characterized by disturbance of the normal 
metamorphosis of an originally properly segmenting ovum : No 
defect, but metamorphosis of part or organ in normal position, 
with derangement of its component parts. 

1. Formation of two or three renal pelves, through unusual arrange- 

ment of the separate renculi of the kidney; also lateral dispo- 
sition of the pelves. 

2. Fusion of all the renculi, to form one kidney: Horseshoe kidney. 

The fusion is usually on the inferior pole, and occasionally asso- 
ciated with dystocia in the pelvic cavity. 

3. Communication between trachea and oesophagus. 

4. Communication between rectum and vagina (cloaca formation). 



324 



PATHOLOGY OF PREGNANCY. 



5. Hermaphroditism us. (Fig. 229.) There are two varieties — 
true aud false. In the former, male and female generative 
organs are present; in the latter, there are a male or female 
generative caual and either male or female genitalia. Of the 
true variety there are three forms : 



Fig. 22 




Hermaphroditismus bilateralis. (Heppxee.) 
a. Glans penis, b. Corp. cavernosa penis, c. Corp. cavernosa of urogenital canal, d. Its bulb. 
e. Its anterior arm. /. Membranous part of urogenital canal, h. Prostate, i. Bladder, k. Ureters. 
I. Vagina, m. Uterus, n'. Fundus uteri, o.o. Tubes, p, p. Tbeir infundibula. q, q. Ovaries. q',q'. 
Ligaments of ovary, r. Right testicle, s. Left testicle, t. Left parovarium, u. Eight parovarium. 
v. Hydatid of Morgagni. n, w. Bloodvessels, x, x. Round ligaments, y, y. Broad ligaments. 
*. Muscle fibres from bladder and vagina. 

1. Bilateral : Ovaries and testicles on both sides. 

2. On one side, an ovary; on the other, a testicle. 

3. Unilateral : On one side, testicles; on the other, ovaries. 

Of the pseudohermaphroditism (Fig. 230), two forms — i. e., male 
and female : 
1. Male pseudohermaphroditism (with testes) falls into three 
subdivisions : 



PATHOLOGY OF THE FCETUS. 



325 



(a) Complete : Testicles present; tubes, uterus, vagina, and 

female external parts. 

(b) Extern us : Testes and male genital canal, with female exter- 

nal parts. 

(c) Internus : Persistence of Miiller's ducts, rudimentary 

vagiua, uterus, and tubes; testes and male external parts. 
2. Feminine pseudobermaphroditismus (with ovaries) falls also 
into three subdivisions : 

(a) Complete : Ovaries, persistent Wolffian ducts; male exter- 

nal genitals. 

(b) Externus : Ovaries, internal female genital canal, external 

male organs. 

(c) Internus: Ovaries; external female genitals; persistent 

Wolffian ducts. 



Fig. 230. 




Spurious hermaphroditism. The round bodies are testicles. (After Hirst and Pieesol.) 

In hitherto observed cases of the true variety, functionally active male 
and female organs were not present; the testicles or ovaries were stunted. 
The majority of the false variety belong to the male sex. The indefi- 
nite location of the organs of generation, and the indefiniteness of all 
external appearances — voice, beard, breasts, sexual instincts. 
III. Arrest of development with prevention of complete ripening of 
the embryo : Persistence of a certain stage in development. 

A. Duplex uterus and vagina through incomplete fusion of Miiller's 

ducts, or through stunting of the same. Rarely the uterus and 
adnexa fail completely; usually a solid rudiment obtains. Uterus 
unicornis arises from absence or stunting of one Miiller's duct. 

B. Cleavage : Most of the cavities and canals of the body are origi- 

nally plates, which bend to form rings in the first month; and by 



326 PATHOLOGY OF PREGNANCY. 

apposition and fusion of their edges, complete the cavities and 
canals. Hinderance of this apposition and fusion results in cleav- 
age of the part. Lips, jaws, palate, neck, trachea, intestines, 
bladder, skull, vertebrae, thorax, and abdomen may thus remain 
separated. Cloaca formation consists in arrested development, 
resulting in communication between rectum, bladder, and the 
genital canal; this arrest of development occurs from the fourth 
week of embryonic life to the middle of the third month. 

1. Cranial and vertebral cleavage : Cranioschisis, rachischisis, crani- 

orachisis are in small part due to embryo-amniotic adhesions, 
mostly to lesions of the central nervous system, which are traced 
to the meninges. (Edema of the cerebro-spinal arachnoid 
(hydromeningocele cerebralis and spinalis) or ectasia of the 
ventricles and central canal of the cord (hydrencephalocele, 
hydrocele medullar spinalis) either prevents fusion of the poste- 
rior vertebral arch or leads to resorption and perforation of the 
bones. Spina bifida is in rare cases a pure hydromeningocele 
spinalis, as a rule only in the inferior portion of the cord : 
hydromeningocele spinalis sacralis or lumbosacral is. When 
the cleavage is situated higher up there is usually a hydromy- 
elocele. This is as a rule associated with marked stunting, 
with usually complete interruption of the cord. The spinal pro- 
cesses usually fail completely in spina bifida. Occasionally an- 
terior vertebral fissure occurs with spina bifida. As a rule the 
protruding sac has in its centre a funnel-shaped deepening. This 
is the place of fusion with the inferior end of the spinal cord. 
Hydrencephaloceles, with and without cerebral atrophy, are 
located usually in the median line, most commonly complicated 
with spina bifida atlantis or cervicalis. Through pressure the 
adjacent areas of brain and cord are destroyed. When the 
sac is very vascular it forms at the base of the skull a red, 
spongy mass : fungus cerebri, pseudoencephalocele. 

2. Cleavage of lips, jaw, and palate (Plate XXIX.). Wolf's jaws : 

chelio-gnato-palato-schisis, single or double sided, through 
imperfect conjunction of upper jaw and palatal processes; the 
first with the anterior end of the frontal process to the middle 
jaw and vomer. The fissure stretches through the lip, upper 
jaw, and palate. The soft palate and uvula are cleft in the 
middle. There is open communication between nose and mouth. 
This anomaly is present in cleavage of chest and abdomen. 
The upper lip and jaw can be simply cleft — unilateral or bilat- 
eral. The cleavage can extend to the nares. In hare-lip either 
a fissure or cleavage obtains, which in the latter case can 
reach the nares. Hare-lip is oftener left-sided; but may be 
bilateral. 

3. Fistula coli congenita is a lateral or median opening, about 2.5 

cm. above the sterno-clavicular joint, on the inner border of 
the sterno-mastoid. The opening is very small, and covered 
with ciliated epithelium, and has a blind end, which is occa- 
sionally sacculated. Lateral fistula is resultant from hindered 
closure of the third and fourth embryonic plates; the median 



PATHOLOGY OF THE FCETUS. 327 

fistula, from absence of conjunction of the third and fourth em- 
bryonic plates. 

4. Cleavage of chest and abdomen lies always in the anterior median 

line of the body. Through hinderance of juncture of the vis- 
ceral plates the entire thorax and abdomen to the navel are 
cleft. The thoracic and abdominal viscera are then displaced 
forward. In simple thoracic cleavage ectopia cordis is usual. 
Sternal fissure is the least degree of thoracic cleavage. Gas- 
troschisis, or abdominal cleavage, may stretch from manubrium 
to symphysis, ensiform to the pubis or navel. In the latter 
case, separation of cord, omphalocele, or umbilical hernia of the 
cord is present. If the abdominal cleavage reaches the pubis, 
vesical cleavage is also present. 

5. Vesical cleavage : Ectopia vesicae urinaria? is characterized by 

the appearance of the posterior bladder wall through a cleft 
abdominal wall. The urethra is also occasionally cleft and 
forms an open border leading to the upper surface of the penis 
— epispadias. Usually cleft bladder is associated with imper- 
fect fusion of the symphysis, absence of clitoris and vagina, 
vaginal atresia, and stunting of penis. 

6. Intestinal cleavage : Fissura intestinalis congenita is a rare com- 

plication of abdominal cleavage. Here, as in vesical cleavage, 
an open caecum or colon ascendens appears in the abdominal 
cleft. 

7. Cloaca formation : 

1. With abdominal and vesical cleavage : Abdominal viscera 

protruded and surrounded by a sac, on the under surface 
of which is seen the cloacal orifice. The intestinal opening 
is located above in the centre of the cloaca; the colon termi- 
nates blind or is absent; the ureters open in the bladder, also 
the seminal vesicles, or, in females, the separately developed 
Miillerian ducts. 

2. With vesical cleavage : In the centre of the cleft bladder is 

the intestinal opening; on the sides, the opening of the 
ureters, and seminal vesicles, or vagina. 

3. With closed bladder: Rectum absent (atresia ani); rectum 

communicates with urinary or genital canal. 

8. Hernia peritonealis congenita: Congenital herniae of the abdo- 

men are characterized by dystocia of the abdominal viscera. 
They originate in the bulging of a less resistant portion of the 
peritoneum, which forms a hole or fissure in the abdominal wall. 
External and internal abdominal hernial are to be differenti- 
ated. The former are visible from without, and resultant from 
outward bulging of the abdominal wall. The latter are not 
perceptible externally. 
External abdominal hernise are : 

H. inguinalis interna, media, externa. 

H. cruralis, ischiadica, perinealis, vaginalis, foraminis ovalis, 
umbiliealis, and abdominalis. 
Internal abdominal herniae are : 

H. diaphragmatica, retroperitonealis, mesenterialis. 



328 PATHOLOGY OF PREGNANCY. 

The majority of these are acquired. Congenital varieties are : 
H. inguinalis externa (outward from the arteria epigastrica, fol- 
lowing the spermatic cord). 
H. umbilicalis : In the foetus a loop of ileum lies within the navel 
opening. 

C. Atresia? : Result from failure of canalization of solid areas of cells, 

destined to become hollowed out, to form sacs and tubes. 

Atresia of pylorus, intestines, ureters, urethra, Fallopian tubes, 
uterus, vagina, hymen. 

Atresia through failure of the skin to bulge toward, and open into, 
perfectly formed canals. 

Atresia oris, ani (usually associated with atresia of vagina, urethra, 
or seminal vesicles). 

Atresia through closure of orifices : Vulva, nose, ear; of the vagina 
and hymen, either total or partial absence of the former from 
obliteration of the Mullerian ducts. Occasionally there is an 
imperforate diaphragm immediately behind the hymen. 

D. Various other embryonic conditions, without corresponding exter- 

nal evidence of the anomaly : 

1 . Diverticula : Of the intestines are congenital wddenings or 

bulgings of the gut; remains of the ductus omphalomesenteri- 
cus, from the time of communication of the intestines with the 
umbilical bladder (allantois). Meckel's diverticulum lies in 
the inferior segment of the ileum, on the convex side, opposite 
the mesentery, about one metre from the Bauhinian valve. It 
is occasionally connected with the navel by the obliterated 
ductus omphalo-mesentericus. 

2. Cryptorchismus : Is the foetal condition. Dystocia of one or 

both testicles, usually one, the organ remaining in the abdom- 
inal cavity. Descent of testes begins about the third month, 
these organs entering the processus vaginalis during the seventh 
month. This anomaly is usually associated with microschismus. 

3. Congenital luxations : Slipping of the head of the joint out its 

socket, from arrested development of the latter. 

4. Club-foot : Pes varus, equino-varus, flat-foot, pes valgus, planus, 

equinus, also the combinations equino-varus and equino-valgus, 
pes calcaneum, also talipes-manus — club-hand. 

In pes varus the outer edge of the foot is turned backward, the 
sole inward; in valgus the inner edge of the foot turns 
under, the sole points backward, the back forward; in calca- 
neus the heel looks backward, the sole forward. The foetal 
placing of the feet corresponds nearly with pes varus; this 
position is readily observed in the new-born. 

Persistence of a foetal condition, arrest of, or overdevelopment, 
and pressure in utero, also muscular contracture of centric 
origin, are causes of these anomalies. Talipo-manus is occa- 
sioned by rudimentary development of the radius. 



PATHOLOGY OF THE FOETUS. 329 



Monstra Per Excessum. 

Malformations characterized by over-large, over-heavy, and super- 
numerary development. 

1. Over-large development : 

1. Giants, macrosomia : Apparent before birth, or commencing im- 

mediately after. Affects in the main the bony skeleton and 
muscular system. Sexual function is very often suppressed. 

2. Abnormally large single parts : 

Acromegalic (Marie) : Enlargement of the pointed parts of the 
human body, hands, feet, nose, lips, chin, tongue, later the 
lower extremity; the distal portion of the forearm, lower jaw. 
The hypertrophy begins in youth or middle life, affects the 
bones and soft parts, and is always associated with muscular 
weakness, sensory disturbances, cephalalgia, and loss of mem- 
ory, also dimness of vision and ansemia. According to Fried- 
reich and Erb, this lesion is seen in several members of the 
same family. 

Macrocephalus; hydrocephalus (apparent cerebral hypertrophy, 
actual atrophy); macroglossia; macrodactylia; dermatocele 
adnata (sac-like, fold-forming hyperplasia of skin); excessive 
size of thyroid, thymus (asthma thymicum), of the ovaries, 
omentum, mesentery (occasions sometimes twisting and incar- 
ceration), of the intestines, ureters, clitoris, penis, uvula. 

3. Abnormal development of hair, and pigment (hirsutio adnata, 

hypertrichiasis). 
H. Supernumerary formation : 

A. Monstra duplicia, twin formation; general or partial duplication 
of the body. Either both twins are equally developed, or one is 
stunted and is parasitic to the other, more or less normally de- 
veloped autosite, from which it is nourished. 
«. Duplication of upper portion of body : Terata anadidyma. 

1 Diprosopus : Double face, one body, two fused, incomplete heads 
(brain absent). 

2. Dicephalus : Double head; one body, two heads. 

3. Ischiopagus : Two upper bodies, a common pelvis, two or four 

lower extremities. (Fig. 231.) 

4. Pyopagus : Two nearly separate bodies; sacrum, coccyx, rectum, 

and occasionally the vagina single. 
/?. Duplication of lower portion of body: Terata catadidyma. 

1. Dipygus : Double body, one head. 

2. Syncephalus (Janiceps) : Two individuals fused together by head 

and hips. 

3. Craniopagus : Two bodies fused on heads, and often shoulders. 
y. Duplication of upper and lower ends of bodies : Terata anacata- 

didyma. 

1. Prosopothoracopagus : Skull cavities separated, under jaws de- 

veloped, breast and neck fused. 

2. Thoracopagus : Fusion of thoraces of two otherwise fully sepa- 

rate individuals (Siamese twins). 



330 PATHOLOGY OF PREGNANCY. 

3. Epignathus : Prosopothoracopagus parasiticus: Foetus in foetu. 

The parasite is associated with the mouth of the autosite, 
usually the hard palate, and projects from the mouth. 

4. Epigastrius : Thoracopus parasiticus : Foetus in foetu. Parasite 

attached from ensiform to navel of autosite. 

5. Engastrius Abdominal inclusion of the parasite. 

6. Rachipagus : Connection of two individuals at only one point on 

the vertebral columns; head, neck, a part of thorax, and lower 
extremities duplicated. 

Fig. 231. 





Ischiopagus tetrapus. 
Mother, a full-blooded Indian, delivered by Dr. Felipe Martinez, San Francisco, Cal. 

B. Monstra triplicia: Triple monsters; are exceedingly rare. 

C. Supernumerary extremities : 

1 . Polymelia: The number of entire or half extremities is increased. 

2. Polydactylie : The number of fingers or toes is increased. 

D. Supernumerary organs. Practically all the separate organs may 

be increased in number. 



Monstra Per Fabricam Alienam. 

Anomalous position of parts or organs : 

1. Situs trans versus, inversio viscerum. Rare. Consists in com- 

plete transposition of otherwise healthy organs. 

2. Dystopia of separate organs. 

Heart : Dextrocardia, ectopia cordis, in thoracic fissure. 
Bladder: Ectopia vesica; urinarise in fissura abdominalis. 



PATHOLOGY OF THE FCETUS. 331 

Spleen ^ 

Stomach I In hernia diaphragmatica congenita, and fissura ab- 

Liver [ dominalis. 

Intestines J 

Os^aries: In inguinal region, or labia majora; anomalous descent. 

Left kidney : In or on edge of pelvic cavity, or in the fovea 

inguinalis. 
Caput coli on left side. 

Colon descend ens, median through radix mesenterii. 
Great hepatic lobe on the left. 



CHAPTER XV. 

PATHOLOGY OF THE FCETUS.— Continued. 
DISEASES OF THE FGETUS. 

Pathological conditions of the foetus are classified as follows : 
Hereditary disease ; 
Developmental errors ; 
Acquired disease; 

Nutritional errors; 
Parasitismus; 
Trauma from 

1. Local pressure effects; 

2. External violence. 

Heredity. Eecent advances in cytology have done much to throw light 
upon the subject of inheritance of disease, especially in the cytology and 
the modus operandi of the fertilization of the ovum. The classical 
researches of Flemming, van Beneden, Bovari, and O. and P. Hertwig 
have proven for all time that fertilization of the ovum consists essen- 
tially in the fusion of an exact quantity of nuclein or chromatin from the 
spermatozoid, with a similar quantity of the same substance in the ovum. 
The resulting segmentation of the ovum must produce cells whose con- 
stituent elements are a combination of chemical — vital — materials from 
both male and female progenitors. This mechanical theory abundantly 
explains the remarkable reproduction in the offspring of striking char- 
acteristics of either or both parents. 

In the light of present knowledge it is impossible to formulate accu- 
rately the ultimate changes of a pathological nature occurring in those 
morphologic elements whose union is to produce a new entity; it can 
merely be assumed that they are essentially chemical — vital. 

It must be that if the reproductive elements of either or both parents 
be impaired or altered in their nature, the change will inhere in the 
foetus, and will be more or less evident, depending upon the condition of 
the other parent and his or her power to offset the deficiency. This 
theory of heredity holds equally for disease as for personal characteris- 
tics. The question thus arises, can such diseases as tuberculosis and 
syphilis be properly hereditary? Assuming both to be of parasitic 
origin, they canuot, in view of what has just been stated. Any heredity 
in these diseases must consist in regressive changes in the reproductive 
elements of one or both individuals, whereby the offspring is deprived 
of^ the power to resist invasion of the parasite, and offers a suitable 
soil for its propagation. The frequent skipping of a generation in tuber- 
cular families supports this view, as it goes to show that in the union 
of a tuberculously inclined individual with a perfectly healthy one, 
the peculiar lack in the reproductive elements of the one is counter- 
balanced by the normal elements in the other, to the extent of producing 
immunity in the immediate offspring. 

(332) 



DISEASES OF THE FCETUS. 333 

In general, it may be said that heredity in disease consists in alteration 
of quality, quantity, or both, of the original elements of fertilization ; 
which alteration persists in the fertilized ovum, and tends to limit its 
normal development, and inaugurates pathological processes in the foetus. 
It cannot at present, however, be denied that these changes may be char- 
acteristic of certain diseases, such as tuberculosis, syphilis, and alcoholism. 

Foetal Infection. It is proved that the fcetns in utero may suffer infec- 
tion. The infection may originate from the mother, father, or both, and 
may be simple or mixed. Its origin may also be external, in the sense 
that the secretions of the genito-urinary canal of an otherwise healthy 
mother may become contaminated with septic organisms from douche 
tubes, etc., which invade the foetus through the liquor amnii (Menge and 
Kronig). 

Foetal infection is acute or chronic. Of the acute processes, scarlatina, 
measles, smallpox, recurrent fever, and erysipelas are recorded, together 
with septic and pyaemic infections, where pathogenic organisms were 
recovered from the organs and tissues of the foetus. Death and expul- 
sion of the foetus are usual in these cases. 

Of the chronic infectious processes tuberculosis and syphilis are the 
chief. Malarial lesions of organs have been described without discovery 
of the plasmodium. Foetal infection occurs through the utero-placental 
tissues, the cord, and the liquor amnii. Normally the latter has strong 
germicidal properties, which may, however, be destroyed. 

Any area of the foetal body may become infected. The determining 
factors are : the primary source of the infection, the resistance of differ- 
ent tissues, the nature of the infecting organism. The organic lesions 
will correspond with the pathogenesis of the infecting germ. Erysipelas, 
multiple abscess, and gonorrhceal ophthalmia are examples of acute para- 
sitic infections. Tuberculosis and probably syphilis are examples of 
chronic infection. 

Inflammation. Acute inflammatory processes are infectious in their 
nature. They are important from their tendency (1) to destroy impor- 
tant structures, as the eye in gonorrhoea; (2) to limit development, as in 
hare-lip consequent upon inflammatory adhesion of the amnion to the 
foetal face; (3) to produce death of the foetus, as in erysipelas. Of the 
chronic inflammatory processes tuberculosis and syphilis are most prom- 
inent and best understood. Congenital hydrocephalus is a consequence 
of chronic meningeal inflammation. 

Hemorrhage. Prenatal haemophilia is recorded. Aside from the hemo- 
philic diathesis, hemorrhage will result from the septic condition and 
trauma. 

In sepsis the hemorrhages are usually petechial, and may be widely 
distributed. Very valuable evidence of the existence of sepsis lies in 
the finding of numerous very small petechia? in the subserous tissues. 
Small hemorrhages may also be caused by cardio-vascular disease or 
anomaly. 

Traumatism will produce large hemorrhages into the cavities of the 
brain, thorax, and abdomen. 

Cephalhematoma results from pressure effects. 

A. Jacobi asserts that small cerebral hemorrhages may occur in the 
foetus, which, primarily unnoticed, produce ultimately epilepsy. 



334 PATHOLOGY OF PREGNANCY. 

The writer has autopsied several cases of fatal cerebral hemorrhage in 
stillbirths, or deaths a few hours post partum, occurring in Dr. Jewett's 
service at the Long Island College Hospital, which originated from a 
cardiac anomaly described below. 

Malnutrition. This condition in the foetus may be due to heredity 
(vide supra), or to disease of the utero-placental tissues or the cord. It 
may result from an abnormally large quantity of amniotic fluid or the 
reverse of this, also from imperfect development of an organic system, 
as, e. g., microcephalus, or general vascular hypoplasia. 

Specific diseases, particularly tuberculosis and syphilis, will cause pro- 
found foetal malnutrition, resulting often in death. In marked cases the 
foetus presents the general appearances of atrophy, the face looks old, 
and the skin is loose. 

Foetal Death occurs during any period of gestation. Very soon after 
conception it will be followed by total absorption of the products. Later 
it will give rise to mole. In the later months of pregnancy the dead 
foetus will undergo maceration, putrefaction — which may involve the 
mother in sepsis — mummification, or calcification. The dead foetus may 
be retained iu the uterus for years. Dr. Lusk reported a case in which 
a normal labor was followed fourteen years later by the removal of a 
calcified foetus. 

Foetal death is caused by hereditary disease, acute infectious diseases, 
foetal tuberculosis, syphilis, and malnutrition. It is also caused by 
utero-placental disease, and by twisting and knotting of the cord, by 
hyper- and oligohydramnios, and by trauma. 

Diagnosis of Death of the Fcetus. The diagnosis is difficult in the early 
months of gestation. The intra -uterine temperature of the mother is 
always higher than the vaginal while the foetus is alive. An equal or 
lower temperature in a uterus containing the product of conception is 
probable evidence of foetal death. On bimanual examination the uterus 
presents a boggy feel. Pelvic tenesmus is usually present in some degree. 

The death of the foetus can, as a rule, easily be determined when it has 
occurred after the period when foetal movements are perceptible. The 
most reliable signs are the persistent absence of foetal heart-sounds and 
of foetal movements. The abdomen ceases to enlarge; the breasts become 
flaccid and diminish in size. 

A fetid discharge from the vagina containing exfoliated epidermis is 
a certain indication of the presence of a dead foetus. Should the foetal 
head present at the pelvic inlet the cranium is found to be soft, and the 
cranial bones loose and movable, overlapping one another. The lips of 
the dead foetus in a face presentation are flabby and motionless. No 
caput succedaneum can form during delivery, as there is no foetal circula- 
tion to make it possible. Large quantities of meconium may be dis- 
charged, though the breech does not present. Yet this frequently occurs 
during the birth of a living child. Should the breech present, the exam- 
ining finger will discover that the anal sphincter does not contract. 
Should the umbilical cord prolapse, it will be found flaccid and pulseless. 

Infection of the mother from the dead foetus in utero is extremely apt 
to occur, and its presence is indicated by depression, furred tongue, chilli- 
ness, fever, a pale and sallow color. 

Errors of Development. Minor malformations, as hare-lip, supernu- 



DISEASES OF THE FCETUS. 335 

inerary fingers, etc., are Anomalies ; major malformations, as anenceph- 
alus, involving a considerable portion of the foetus, are Monstrosities. 
Up to the time of Lenierey, Winslow, and A. v. Haller, monsters were 
regarded as wonders of evil omen. 

Winslow and Haller regarded developmental errors as primary anom- 
alies of the seed, present in it before fertilization; while Lemerey regarded 
them as due to interference with the processes of embryonic development. 

As embryology became better known, J. F. Merckel and Geoffroy- 
Saint-Hilaire, father and son, treated the whole subject of teratology more 
thoroughly, and called attention to the relationship between arrest of 
normal development and persistence of the foetus in a certain stage of 
development. 

Forster was the first to collect and classify the literature on this sub- 
ject; and, following him, Ahlfeld rearranged and extended it in a series 
of plates. (Thoma.) 

Many interesting experiments have been made by such investigators 
as Geoff roy-Saint-Hilaire, Panum, Dareste, L. Gerlach, the brothers 
Hertwig, Roux, and others, with the result of proving that anomalies in 
embryonic development may be induced by mechanical means, such as 
separation of the elements of the segmenting ovum and axial change of 
its position during segmentation. These facts show the influence of 
environment upon foetal development. Thoma, of Dorpat, draws atten- 
tion to the fact that twins occurring from a single ovum develop circu- 
latory disturbances in the nature of venous obstruction, with hepatic and 
other organic congestions due to anastomosis of the vascular systems of 
both individuals. Others have produced twins in the ova of rana by 
permanently inverting the primitive streak. 

Notwithstanding all the brilliant work in this direction, we still know 
but little regarding the etiology of anomalous development. It is pretty 
clear that heredity, malposition of the blastoderm, intoxications and 
infections of the foetus in utero, all play a part in the arrest of develop- 
ment, as well as oligohydramnios and trauma. 

As Thoma well puts it, foetal disease per se is also significant in the 
production of anomalies : as increase of amniotic fluid, oedema of the 
embryonic tissues, organized adhesions between the foetal tissues, and 
between these tissues and the amnion, and even isolation of areas of 
embryonic tissue, e. g., dermoid cyst. 

The same author also justly remarks that aside from gross errors in 
development, giving rise to extensive deformity, it is very important to 
remember that anomalies may obtain in single organs, which in time will 
produce secondary disease. Many aplasiae will make life impossible to 
the child after birth; others will handicap it, and still others will con- 
stantly menace its existence. Practically those anomalies which tend to 
limit the possibilities of the child after birth are of greater importance 
to it; while monstrosities are of greater importance to the mother in the 
often grave complications they occasion during parturition. 

Systematic Organic Lesions. There is not space in an article like this 
for a detailed description of all the lesions of the foetal organs. In 
general, it may be said that the fundamental principles underlying these 
lesions are identical with those governing lesions in the adult, the one 
difference being rather of result — i. e., arrest or alteration of develop- 



336 PATHOLOGY OF PREGNANCY. 

ment in many instances in the foetus. In describing some of the more 
important organic diseases, only such minor anomalies will be considered 
as tend to induce other pathological conditions. 

Heart Endocarditis is almost always in the right heart; is rarely 
acute, usually chronic, and due to syphilis. 

Myocarditis is acute (from infection, Menge and Kronig), or chronic, 
and due to syphilis. In the latter case it is interstitial. 

Endocarditis, with anomalous or incompetent valves may produce a 
vicious circulation, and chronic venous hyperemia; cases are reported in 
which typical nutmeg-liver and renal cyanosis complicated this lesion. 
Hemorrhage, marked or slight, may also be caused by it, and may in- 
volve any organ, notably the brain and lungs. Through the courtesy 
of Dr. Jewett, the writer has been able to autopsy several stillbirths 
and infants dying a few hours after birth in the maternity wards of the 
Long Island College Hospital, in which it was revealed that the pul- 
monary artery was immediately confluent with the thoracic aorta 
(through a large and persistent ductus arteriosus?), with extremely small 
branches running to the lungs. The right ventricle was hypertrophic. 
Aside from a few petechia? in the subserous tissues generally, all of the 
cases showed very considerable hemorrhage at the base of the brain and 
around the medulla and pons. In all the parturition was normal, with 
not the slightest evidence of sepsis. In some of the cases there was 
pulmonary hemorrhagic infarct. In these cases, if the ductus arteriosus 
be regarded as the source of confluence between the pulmonary artery 
and the thoracic aorta, its structure was unusually thick, and in every 
way similar to the other portions of the vascular channel at this point. 
The writer believes that this may be a more common condition than is 
generally supposed. 

According to Orth, who recites a very remarkable instance, hypoplasia 
cordis, with general vascular hypoplasia, is a very important foetal con- 
dition, bearing direct relation to chlorosis in the young. His patient, a 
girl in her teens, died with marked chlorosis, and the autopsy revealed an 
infantile heart with an aorta that scarcely admitted an ordinary lead- 
pencil within it. It is probable that this condition may cause foetal 
malnutrition not infrequently. 

Tachycardia and arrhythmia are caused by nervous anomaly, general 
cardiac insufficiency, systemic foetal infection, uterine pressure, and foetal 
debility. 

Tuberculosis is rare, and always discrete. 

Bloodvessels. Anomalies of the vascular distribution are directly re- 
sponsible for lack in development of entire parts, as, e. g., a cerebral 
hemisphere. 

Hemorrhage is by rhexis from cardiac lesion, or trauma, pressure in 
utero, efforts to respire before or during parturition, and haemophilia, 
and by diapedesis in sepsis, icterus neonatorum, and probably haemophilia. 
The hemorrhage of sepsis is very important, as it affords a point in diag- 
nosis of the condition. The hemorrhage is always multiple and petechial, 
or at least small, and most conspicuous in the subcutaneous and subserous 
tissues. 

Vasculitis. Acute vascular inflammation may supervene in the foetal 
bloodvessels, and involve the adventitia or intima, or be diffuse ; but the 



DISEASES OF THE FCETUS. 337 

most important inflammatory changes are chronic, and due to syphilis. 
Here there is active, small round-cell infiltration, with hyperplasia of 
connective tissue. Either the outer or inner, or both, coats are involved; 
and the lamina of the vessels may be diminished and eccentric. It can- 
not be doubted that such chronic vascular inflammations may arrest 
development, and, by inhibiting osmosis, produce profound nutrition 
disturbances. 

Finally, microscopic examination of the tissues of foetuses suspected 
to have died of infection has yielded positive results to a number of 
investigators. The writer, through the courtesy of Dr. Jewett, observed 
a multiple hepatic infection in an infant dying shortly after birth, where 
microtome sections revealed numerous foci of small round-cell infiltra- 
tions, and, amongst these cells and in the intralobular capillaries, micro- 
cocci. Menge and Kronig record a case in which septic anaerobes were 
found in the right heart of a stillbirth, where the liquor amnii had 
become infected. 

Hyperplasia? aud aneurisms of the arterioles, capillaries, and venules 
are common, and form verrucose naevi and so-called birth marks. 

Lymphatics. These structures are the seat of inflammation and are 
associated with the lesions of elephantiasis fceti. They are often angi- 
omatous, and are common carriers of micro-organisms. 

Lungs. Pulmonary oedema and hemorrhage occur as results of cere- 
bral and cardio-vascular lesions, pressure effects in parturition, trauma, 
and sepsis. Hsemothorax from trauma is recorded. Atelectasis is normal 
until birth; it persists after birth from prenatal centric lesions and defects, 
or obstruction of the respiratory tract with inhaled mucus. It is partial 
or total. 

Disseminated pneumonia is frequent in foetal infection. 

Syphilis gives rise to " white pneumonia 7 ' (Osier) and interstitial and 
vascular hyperplasia. 

The writer has seen undoubted septic pneumonia in several cases of 
stillbirth in puerperal sepsis. Cross section of these lungs revealed 
characteristic areas of infiltration, which microscopic examination proved 
to be foci of small round cells, whose centres were in coagulation necrosis. 
Pleuritis has been recorded. 

Spleen. Aside from anomalies, this organ will show the characteristic 
changes of sepsis, and, it is claimed, of malaria. 

Primce Vice. Acute inflammatory lesions may obtain from infection. 
Menge and Kronig find evidence of it in cases where infection from the 
amniotic fluid apparently started in the stomach and intestines. Tuber- 
culosis and syphilis occur in the stomach and intestines, and the mesen- 
teric and retroperitoneal glands. 

Of the anomalies, one or two are liable to produce trouble later in life. 
The writer has autopsied three cases of fatal perforative appendicitis 
where situs transversus was found. The caput coli in one case was 
literally transposed; in the other two it was displaced, and closely 
adherent to the sigmoid flexure. Diverticula} are seen in any part of 
the canal, and may be sufficiently large to produce serious trouble. The 
stomach may be nearly inverted, and the cardia brought lower than the 
pylorus; or it may assume a vertical position. Gastric hypoplasia may 
be marked. 

22 



338 PATHOLOGY OF PREGNANCY. 

Atresia ani and recti may be of sufficient degree to prove fatal, or may 
be amenable to operation. 

Liver. Reveals characteristic structural changes incident to cardio- 
vascular lesions and the parenchymatous changes of septic infection. 
It may be the primary focus of infection in the foetus, the source of 
which is the cord or the liquor amnii. (Menge and Kronig.) 

Icterus neonatorum will result from such infections, and may be com- 
plicated with fatal hemorrhage. 

The writer has seen, and Menge and Kronig report, cases in which 
microtome sections revealed foci of small round cells, micrococci in the 
writer's case, and a short bacillus in those of Menge and Kronig. 

Kidneys. Aside from their interest merely as curiosities, the renal 
anomalies are very important from their relative frequency and the bear- 
ing they have on surgery. A single kidney may be developed, or the 
two may fuse to form a horseshoe, or both may locate in the pelvis. 
One or both organs may be destroyed by hydronephrosis due to atresia 
of the genito-uriuary canal at some point. 

All of the changes due to renal cyanosis may be present as results of 
cardio-vascular lesions. These organs also show the general changes of 
infection; and localized areas of infection have been found, especially in 
the Malpighian pyramids (Menge and Kronig). 

A very important congenital condition of the kidney, described by 
Orth, Rosenstein, and others, is multiple cystic degeneration of the cor- 
tical tubules. According to Rosenstein the crypts may be so numerous 
as to leave but little functionating tissue. The cysts never attain a 
large size. The condition is often accompanied with renal hemorrhage, 
and is, unfortunately, usually bilateral. The writer has seen one such 
case which came to operation for renal hemorrhage and tumor. The 
right kidney was very large, weighing about three pounds, and studded 
with hundreds of cysts, which varied in size from a pullet's egg to that 
of a pin-head. In this case both organs were involved, and the patient 
died of uraBmia. The etiology of these cystic kidneys is very obscure. 
Not infrequently an infant dies within a few days after birth, and the 
kidneys are found to contain uric-acid infarcts, which are located, as a 
rule, in the medullary portions of the collecting tubules. According to 
Ziegler these infarcts form after birth as a result of the inability of the 
renal parenchyma to sustain the increased work thrown upon it. 

Genital Organs. Aside from anomalies, the organs of generation may 
be the seat of infection, which is acute or chronic, depending upon the 
nature of the infection. 

Osseous System. Osteomalacia, premature ossification, general hyper- 
plasia, and infections of various nature occur. 

" Spontaneous fracture" has been recorded, and is regarded as due to 
uterine contractions and trauma. 

Luxations of the joints are due to anomalous development or oligo- 
hydramnios. 

Oligohydramnios is in causal relation with talipes or similar condi- 
tions. 

Centric Talipes. Centric lesions will also produce them by causing 
muscular contracture. 

Muscular System. Aside from anomalies of development, the muscles 



DISEASES OF THE FCETUS. 339 

are subject to the same changes occurring in other tissues due to general 
causes. 

The Shin shows the characteristic lesions of acute specific diseases, such 
as scarlatina, smallpox, erysipelas, etc. Syphilitic and tubercular lesions 
have also been observed. 

(Edema, ichthyosis, and many other lesions of the skin have been 
recorded; but, as yet, their pathology is entirely obscure. 



CHAPTER XVI. 

ABORTION AND PREMATURE LABOR. 

Definition and Classification. The term abortion signifies the expul- 
sion of the products of conception before the sixteenth week of gestation, 
at a time when the placenta is not yet fully formed, and hence when it 
cannot be expelled or expressed (Crede's method) in its entirety. 

Premature labor is applied to the delivery of a foetus at any period 
from the time after it has become viable to within a few weeks before 
the normal termination of pregnancy. It is made to cover the period from 
the twenty-eighth to the thirty-sixth or thirty-eighth week of gestation. 

For the intervening period (from the sixteenth to the twenty-eighth 
week) not included by abortion and premature labor, the term " miscar- 
riage" is generally employed. The use of the latter term, though sanc- 
tioned by time and habit, is not satisfactory, as admitted by many authors 
who have submitted to the custom. It would appear that the term 
" immature labor" would be more appropriate. The processes of expul- 
sion at this period of gestation resemble in a measure those of labor at 
full term, and they may be looked upon as constituting a labor in min- 
iature. But the foetus, though it may be born alive, is so immature in 
its development that it cannot be reared — in other words, it is non- 
viable. Hence, the adjective " immature " would fitly denote at once 
the nature of the delivery and the condition of the foetus. 

Viability of Foetus. Assigning the twenty-eighth week as the period 
of viability is somewhat arbitrary ; for with the modern incubators and 
improved methods of feeding, foetuses born at an earlier period of preg- 
nancy have been known to live and thrive. 

Ribemont-Dessaignes and Lepage 1 make the weight of the foetus a 
criterion of its viability. They consider it non-viable if it weighs less 
than 1000 grammes, and viable if it weighs more than that. French 
authors make the following divisions: (1) Ovular abortion, that which 
takes place before the twentieth day. (2) Embryonic abortion, that which 
takes place from the twentieth to the eightieth day. (3) Foetal abortion, 
that which takes place from the fourth to the seventh month. This 
division is confusing and has no practical value. 

Abortion is artificial or spontaneous according as it is or is not evoked 
intentionally. 

Artificial abortion is spoken of as therapeutic when it is done for justi- 
fiable cause, and criminal when it is done for improper or immoral 
reasons. 

Frequency. It is generally stated that from 30 per cent, to 40 per 
cent, of all married women abort before they reach the age of thirty 
years. But it is next to impossible to ascertain reliable statistics on 
this point. Many women abort at an early period of pregnancy 

1 Ribemont-Dessaignes et Lepage. Precis d'Obstetrique. Paris, 1897. 
340 



ABORTION AXD PREMATURE LABOR. 341 

without knowing it, thinking that the menses were merely delayed and 
then came on rather profusely. Again, other women conceal the fact 
from motives of delicacy. The estimates of authorities differ widely. 
According to some writers, abortion occurs once in five or six pregnan- 
cies. Hegar 1 estimates the frequency as once in eight pregnancies. M. 
Bossi 2 states that to every one hundred pregnancies at full term there 
are twenty-five abortions. 

Whitehead, 3 whose statistics are universally quoted, states that thirty- 
seven out of every one hundred mothers abort before they reach the age 
of thirty years. * His statistics, however, were based upon the lowest 
classes of Irish peasants, who were living in Manchester in great priva- 
tion and amid most insanitary surroundings, and with whom very early 
marriages Avere the rule. 

Time of Occurrence. Abortion occurs most frequently in the third 
month — that is, between the ninth and sixteenth week of pregnancy. 
This is generally the case when it is due to diseases and malpositions 
of the uterus, as chronic endometritis and backward displacements. It 
is especially liable to take place at the menstrual dates. It is very 
probable that this greater frequency at the third month and in the begin- 
ning of the fourth month is clue to the fact that at this time important 
changes are taking place in the attachment between the ovum and 
uterine wall. It is the period of the formation of the placenta. The 
chorionic villi situated on the periphery of the ovum undergo atrophy, 
while those situated in contact with the uterine wall (the decidua serotina) 
become hypertrophied. 

The extent of surface by which the ovum is attached to the uterus is, 
therefore, decreased, though at the point where it still remains attached 
— the site of the future placenta — it strikes deeper roots into the uterine 
tissues. When syphilis is the cause the pregnancy is more likely to be 
interrupted at the sixth, seventh, or eighth month of gestation. 

It is commonly believed that early, especially first, pregnancies have 
more frequently a premature termination than those wdiich come after. 
Whitehead 3 observed, however, that the third and fourth pregnancies 
and one or two of the last, those, namely, which occur near the termina- 
tion of the fruitful period, are most commonly unsuccessful. This is 
particularly interesting, inasmuch as Whitehead's observations relate to 
a class of people among whom the girls married at the early age of thir- 
teen and fourteen years. This experience corresponds with that of the 
author with Russian Jews, who also are given to early marriages. 

Etiology. It may be stated, as a general law with some exceptions, 
that all etiological factors act either by exciting uterine contractions 
directly, or indirectly by causing the death of the foetus, which in turn 
is followed by uterine contractions. For practical purposes the causes 
of abortion may be divided into those acting through the father, those 
acting through the mother, and those affecting the ovum. 

Paterxal. By far the most important and frequent cause of abor- 
tion proceeding from the father is syphilis. It is frequently overlooked 
because the manifestations of the disease may no longer be present, 

1 Hegar. Monatsoh. f. Geburtsh., Bd. xxxi. S. 34. 

2 M. Bossi. Annali di Osteticia et Ginecologia, No. 2, 1898. 

3 Whitehead. Abortion and Sterility, etc. London, 1847. 



342 PATHOLOGY OF PREGNANCY. 

or they may never have been so marked as to excite the attention 
either of the patient or his physician. Tuberculosis, lead-poisoning 
(C. Paul/ Rennert 2 ), alcoholism, extreme youth, great old age, excessive 
venery, may all act as causative factors. Ribemont-Dessaignes and 
Lepage 3 relate an observation which would go to prove that excessive 
coition may be a cause of abortion. Of thirty cows that were served 
by the same bull within a short period, the fifteen that were served first 
went to full term, the last fifteen all aborted. 

Material, (a) Acute infectious diseases, especially typhoid fever, 
influenza, smallpox, cholera, scarlatina, measles, pneumonia, and acute 
intermittent fever. The more severe the affection, and the higher the 
fever and the more continuous it is, the more likely is abortion to occur. 
The germs may act directly on the foetus through the placental circu- 
lation, or the attendant high temperature may destroy the foetus (M. 
Runge 4 ), or placental hemorrhages may occur as a result of the patho- 
logical changes set up by the constitutional affection (Zweifel 5 ). 

(6) Chronic infectious diseases : tuberculosis, syphilis, and severe 
malarial poisoning (T. G. Thomas 6 ). Of these, syphilis is again by far 
the most common cause. According to Roemheld, 7 27 per cent, of all 
interrupted pregnancies are due to syphilis in the mother. 

(c) Organic diseases: cardiac affections, especially those of the left 
orifice (A. McDonald, 8 E. Ley den 9 ); chronic nephritis, causing white 
infarcts of the placenta and premature separation of the placenta. 

(cl) Constitutional affections : diabetes mellitus, progressive pernicious 
anaemia, lead-poisoning (Benson-Baker, 10 Rennert 11 ), acute anaemia fol- 
lowing sudden great loss of blood. 

(<?) Emotional disturbance: sudden shock, severe fright, profound 
sorrow, etc., may at times bring about the interruption of pregnancy. 

(/) Traumatism : this as a cause of abortion must always be accepted 
with considerable scepticism. In a healthy condition of the uterus 
and the ovum the pregnant woman may sustain the severest injury 
without aborting. On the other hand, when the utero-placental vessels 
are fragile, as they are in some constitutional diseases — e. g., syphilis — 
a slight traumatism, such as is occasioned by a fit of coughing, straining 
at stool, retching and vomiting, may be attended by a hemorrhage 
between the placenta and the uterus, and consequent abortion. A severe 
blow on the abdomen after the third or fourth month, when the uterus 
has risen into the abdominal cavity, may act as an exciting cause, either 
by causing the death of the foetus directly or by bringing about a sepa- 
ration of the placenta from the uterine wall. In these instances, as a 
rule, the symptoms of abortion follow immediately the receipt of the 
injury. The laity, however, are only too prone to ascribe the interrup- 
tion of pregnancy to the most trifling accidents, such as a misstep or a 
simple fall. 

1 C. Paul. Arch. gen. de Medecine, 1860. 

2 Rennert. Arch. f. Gyn., 1881. 

3 Ribemont-Dessaignes et Lepage. Precis d'Obstetrique. Paris, 1897. 

4 M. Runge. Volkniann's klin.'Vortrage, No. 174, and Arch. f. Gyn., Bd. xii. S. 16. 

5 P. Zweifel. Lehrbuch der Geburtshiilfe, Stuttgart. 1895. 

6 T. Gaillard Thomas. Abortion. 1890. 

7 L. Roemheld. Inaug. Diss. Mainz. 189o. 

8 A. McDonald. Obstetrical Journal of Great Britain, 1877. 

9 E. Leyden. Zeitseh. f. klin. Med., 1893. 

10 Benson-Baker. Obstet. Trans., London., 1867, vol. viii. p. 41. 

11 Rennert. Arch. f. Gvn.. 1881. 



ABORTIOX AND PREMATURE LABOR. 343 

Major operations (ovariotomy and even myomectomy) have been per- 
formed on pregnant women without any deleterious influence upon the 
course of gestation. Operations on the vulva, however, are said to be 
more dangerous in this regard (Schauta 1 ). Yet the author once excised a 
very much hypertrophied hymen, necessitating extensive suturing of the 
resulting wound, in a young woman in the fourth month of pregnancy, 
and she went to full term. 

Too frequent indulgence in sexual intercourse not only lessens the 
virility of the spermatozoa, as we have already seen, but acts also as a 
traumatism and brings about a hyperemia of the uterus. Hence, abor- 
tion is common in newly married women during the first five or six 
weeks of married life. 

Sea voyages, even in absence of storms, and high altitudes (Sancerotte 
and Jourdanet, quoted by Charpentier) are said occasionally to cause 
premature expulsion of the foetus. 

Drags. Certain drugs — ergot, savine, quinine, salicylate of sodium 
(the author 2 ), and a host of others — are supposed to possess the property 
of bringing on abortion. It is doubtful whether they can do this in a 
normal condition of the uterus. When a strong predisposition exists, 
however, quinine and salicylate of sodium should be administered with 
great caution. 

Local Causes. Backward displacement of the uterus is a very com- 
mon cause (58 per cent., Roemheld 3 ), in which condition it may be due 
to the inability of the fundus to rise above the promontory, and then it 
usually takes place between the third and fourth month. The termina- 
tion of pregnancy may, however, occur later, and then it is said to be 
due to the chronic endometritis and metritis that are usually associated 
with the malposition. 

The other conditions of the uterus that may give rise to abortion are 
chronic metritis, chronic endometritis, laceration of the cervix, muti- 
lation of the cervix through an unskilful amputation, adhesions of 
the uterus to the pelvic wall or to other adjacent structures, fibromyo- 
mata or malignant growths, immature and abnormal development of the 
uterus (uterus bicornis, pregnancy taking place in a rudimentary horn), 
neighboring tumors, and pelvic deformities, which may interfere with 
the growth of the uterus. Artificial forward fixation of the uterus, 
either to the vagina or to the abdomen, has been known occasionally to 
produce abortion from inability of the fundus to grow, owing to too 
firm union with the vaginal or the abdominal walls. Marked disease 
of the adnexa may interrupt the pregnancy. 

Habitual Abortion: Lastly, there are some women who abort over 
and over again, and in whom the most thorough investigation fails to 
find a reasonable cause. To this condition the term "habitual abortion" 
is applied. To attribute the tendency to a hypersesthetic condition of 
the uterine system of nerves (T. G. Thomas 4 ) or to congestion of the 
uterus (Napier 5 and others) is merely begging the question. By many 
authors the term habitual abortion is used interchangeably with re- 

1 Friedrich Schauta. Lehrbuch der Gesammten Gyniikologie, Leipzig und Wien, 1896. 

2 H. N. Vineberg. New York Med. Journ., vol. lix. p. 785. 

3 L. Roemheld. Inaug. Diss. Mainz, 1895. 

4 T. Gaillard Thomas. Abortion. 1890. 

5 W. D. L. Napier. Trans. London Obstet. Society, 1890, p. 389. 



344 



PATHOLOGY OF PEEGXAXCY 



peated abortions. This is misleading from an etiological standpoint, to 
say the least. 

Foetal. Under this heading are included all the pathological changes 
that may affect the ovum and its envelopes. Here, again, syphilis plays 
an important role by producing changes in the ovum or in the placenta 
which lead to the death of the foetus and to consequent abortion. It 
may kill the foetus directly through causing marked pathological changes 
in important organs, and the membranes may remain unaffected (Zwei- 
fel 1 ). 

Syphilis may be transmitted directly from the father, and the foetus 
die of it without infection of the mother ensuing. According to Napier, 2 
when syphilis is the cause, the death of the foetus occurs most frequently 
between the third and eighth months, very seldom before that time. 

Various diseases of the decidua, placental apoplexy, and the different 
degenerations of the placenta may bring about abortion by causing death 
of the foetus. Polyhydramnios, by causing pver-distention of the uterus, 
may lead to premature expulsion of its contents. 

Abnormal insertion of the placenta (placenta prsevia) is very prone to 

i Fig. 232. 




Aborted ovum. Deciduae and ovum complete, o. i. corresponds to the decidua situated at the os 
internum ; t.t., to the decidua situated at the openings of the tubes. 



1 P. Zweifel. Lehrbuch der Geburtshiilfe, Stuttgart, 1895. 

2 ^ . D. L. Napier. Trans. London Obstet. Society, 1890, p. 3£ 



ABORTION AND PREMATURE LABOR. 34. j 

induce abortion, though it generally plays a more important role in the 
production of premature labor. 

Pathology. To describe all the pathological changes of the mem- 
branes and ovum that are observed in abortion would lead us beyond 
our province. We will merely give those that we consider necessary for 
the elucidation of our subject. 

In abortion there is invariably a rupture of the bloodvessels that con- 
nect the ovum and the uterine wall — in other words, of the utero- 
placental vessels. The effusion of blood usually takes place in the 
decidua vera, but not infrequently it forces its way between the decidua 
and chorion, also at times even breaking through the decidua and 
amnion and filling the amniotic cavity with blood. In abortions of 
more advauced pregnancy, after the formation of the placenta the blood 
is effused between the placenta and the uterine wall. In this manner the 
placenta is detached to a greater or less extent from its uterine insertion. 
In studying the pathological anatomy and mechanism of abortion we 
cannot do better than quote Dr. Berry Hart's 1 excellent description: 
Two forms must be considered : (1) Normal or complete; (2) abnormal 
or incomplete. 

Fig. 233. 





|L 

Closed. Open. 

Ovum of the first month. The deciduse have remained behind, the amnion 
has broken through the chorion ; natural size. (Winckel.) 

Normal or Complete. There are two varieties depending upon the 
size of the ovum proper covered by reflexa. In the first variety, when 
the ovum is small, the decidua is separated in its whole extent and is 
expelled with the ovum. This is the exception. 

In the second variety the decidua vera separates over the lower uterine 
segment, and the ovum proper is covered by reflexa driven down into 
the cervical canal, but remaining attached above by an apparent neck to 
the decidua of the retracting upper segment. The rest of the decidua 
is then separated and the whole expelled. 

Abnormal or Incomplete. The following two varieties may occur : 

1, The foetus alone or the entire ovum with its chorion may be ex- 
pelled through the reflexa. The decidua vera and reflexa are retained or 
expelled later. 

2. The ovum covered by reflexa may be expelled, the apparent polypus 
neck having been snapped. The part thus expelled is often mistaken by 
the practitioner for the entire ovum. He sees an oval sac covered by 
decidua with amnion below this and containing liquor amnii and the 
foetus. It is really only the ovum proper covered by reflexa, and the 
decidua vera and serotina in the shape of a sac are still in utero. 

1 D. Berry Hart. Trans. Edinb. Obstet. Society, 1890-91, p. 20. 



346 PATHOLOGY OF PREGNANCY. 

It happens occasionally that the extravasation of blood into the mem- 
branes takes place at different times, allowing the coagulation of the 
blood in strata, thus forming what is known as a blood mole. Should 
the process of abortion be slow in culminating, the coloring matter of 
the blood becomes absorbed, the blood strata undergo partial organiza- 
tion, and there results what is known as a fleshy mole. This may form 
anew a connection with the uterine wall and be retained for an indefinite 
period. These moles have generally a characteristic appearance, being 
covered with the decidua serotina and reflexa, and having remnants of 
the decidua vera hanging from them. On cutting them open the foetus 
or ovum is found in the centre of a smooth-lined cavity — the amniotic. 
The foetus is very small in comparison with the size of the expelled 
mass, and may be overlooked unless searched for with a magnifying 
glass. _ 

In incomplete and neglected abortions the retained portions of decidua 

Fig. 234. 




Early pregnancy (two months), o. e., os externum; o.i.,os internum; /.a., upper limit of firm 
attachment of peritoneum ; pi., placenta ; d. v., decidua vera ; d. p., decidua reflexa. (Hofmeiee.) 

or of placenta may develop into a decidual or placental polypus in the 
following manner. The uterus, through contractions, endeavors to expel 
its contents, the placental residua are thus loosened in some places and 
hemorrhage occurs. The blood is deposited upon the placental remains 
in layers, forming a smaller or larger polypoid mass, which acquires a 
new connection with the uterine tissues. Decidual polypi are formed 



ABORTIOX AXD PREMATURE LABOR. 347 

in exactly the same way (Winternitz 1 ). These polypi may remain for 
weeks, or even for months, in the litems without undergoing decomposi- 
tion and without causing a fetid discharge or elevation of temperature. 
AVinternitz 2 relates a case that came under his treatment six and one- 
half months after the abortion. The removed mass was free from any 
fetid odor. It is these formations that frequently are the cause of irreg- 
ular hemorrhages, continuing for a long time after a supposed complete 
abortion. 

The retained placental and decidual residua do not always behave in 
this benign manner. They may undergo decomposition, and if the 
drainage is not free, as is most frequently the case, owing to the closure 
of the cervix, septic infection of a more or less serious nature may result. 

The foetus in cases of abortion is, as a rule, smaller than the period of 
pregnancy would indicate. This is particularly true of cases of fleshy 
mole, where the ovum dies at an early stage. It may then become 
entirely absorbed, or exist merely as a small white strand in the centre 
of the amniotic cavity. In other cases, after undergoing partial macera- 
tion in the liquor amnii, the foetus may become mummified, and be thus 
expelled, or, again, putrefaction may set in and the putrid mass be 
expelled piecemeal. 

Symptoms and Clinical Course. The symptoms of abortion vary at 
different periods of pregnancy. In the first six or eight weeks, pro- 
dromal symptoms are rare. The woman has not yet, as a rule, expe- 
rienced any of the symptoms of pregnancy. The abortion has all the 
characters of a retarded and profuse menstruation, which the patient 
often thinks it is. She loses considerable blood, and frequently passes 
large clots. Her suffering generally is not great- — not more severe than 
that which ordinarily accompanies menstruation. Skene 3 speaks of 
some cases in which the hemorrhage takes place only at night when the 
patient is lying down. The explanation he offers is that the ovum dies 
and is not expelled, but acts as a valve at the os internum when the 
patient is in the erect position. When, however, " she lies down, it falls 
away from the os, and a hemorrhage takes place, the blood accumulating 
in the uterus when she is standing or walking about. " At times there 
may be considerable uterine colic. If the woman recognizes the fact 
that she has been pregnant she will often state that " everything" has 
come away in the form of a large fleshy mass, which is usually nothing 
more than a large blood-clot partially organized. At this stage generally 
the ovum is rarely found; it passes off with one of the clots, or with 
the shreds of the decidua. 

On bimanual examination the uterus is found enlarged, especially in 
its antero-posterior diameter, to about double the size of the non-pregnant 
uterus. The cervix may be quite closed or very slightly open. 

In other cases the cervix will be found quite open, and the finger will 
detect just beyond the external os a smooth, globular, elastic mass, appar- 
ently attached to its interior. This, as we have already seen, is the 
ovum driven into the cervix, but arrested in its expulsion by the strong 
muscular fibres of the external os. 

In a third class of cases the uterus will be found slightly, if any 

1 E. Winternitz. Sam. Zwanglos. Abhand. aus dem Gebiete der Frauenbeilk., Bd. ii. Heft 4. 

2 Ibid. 3 A. J. C. Skene. Medical News, 1884. 



348 PATHOLOGY OF PREGXANCY. 

larger than normal. The continuance of the hemorrhage in these cases 
will furnish us the only evidence that all the products of conception have 
not yet been expelled/ It is important to bear in mind that, though the 
uterus is not enlarged and the cervix is not patulous, the hemorrhage in 
all probability is due to retained decidua, for it is generally stated that 
retained decidua is always indicated by a patulous cervix. AVe have 
seeu cases in which profuse hemorrhage continued for weeks with the 
local conditions just mentioned, and which were due to the presence of a 
fragment of decidua, perhaps not larger than the finger-nail. Diihrssen, 1 
who has had a very extensive experience as the assistant of Gusserow at 
the Charite in Berlin, says that " the retention of portions of the decidua 
vera is not the exception, but the rule." 

In a very small percentage of cases where the ovum and its membrane 
are virtually expelled, either en masse or separately, the hemorrhage 
ceases in four or five days, and a local examination will detect merely a 
softened uterus, perhaps slightly enlarged. 

After the second month of pregnancy premonitory signs are generally 
present. The patient will complain of bearing-down sensations in the 
lower part of the abdomen, and she will suffer more or less from a feeling 
of weight in the pelvis, from backache, from frequent micturition, and 
from a slight mucous or watery discharge. Pains resembling labor pains 
may precede any marked hemorrhage, though at times there may be con- 
siderable loss of blood before labor pains are experienced. The further 
advanced the pregnancy the more likely will it be that the labor pains 
will precede the hemorrhage, though the opposite may obtain at any 
period of prematurity. 

On local examination the cervix may be found closed or partially 
open, according to the advance the efforts of the uterus have made to 
expel its contents. The uterus will be found to correspond in size with 
the given period of pregnancy, providing the foetus has not yet been 
expelled. The latter fact is readily ascertained from the woman herself 
or any of the attendants, as the foetus has now reached a stage of devel- 
opment which makes it easily recognizable by the laity. 

The placenta may be expelled entire after the delivery of the foetus, 
or it may come away piecemeal — a much more frequent occurrence. In 
the latter class of cases portions of the placenta may remain attached to 
the uterus for an indefinite period, as already stated, causing from time 
to time uterine hemorrhage. In cases of protracted abortion the woman 
shows signs of ill health. She grows more or less anaemic, has a some- 
what haggard appearance, and feels too weak to carry on her usual duties. 
Of course, in cases of incomplete abortion, when the retained products 
undergo decomposition and septic infection occurs, the usual symptoms 
of sepsis manifest themselves, and the temperature usually runs high. 
It must be borne in mind, however, that we may have a severe form of 
sepsis with scarcely any elevation of temperature. These cases are gen- 
erally very treacherous, as the poison acts chiefly on the heart. 

Locally we may find an exudate in Douglas's cul-de-sac or at the 
base of one of the broad ligaments. In other cases there will be the 
local signs of pelvic peritonitis. 

In abortions prior to the second month there is no true lochial dis- 

1 Diihrssen Archiv f. Gyn,. Bd. xxxi. Heft 2, S. 161. 



ABORTION AXD PREMATURE LABOR. 319 

charge, but rather a sero-sauguineous flow lastiug three or four days. 
Iu the later mouths the flow resembles more or less that following labor 
at full term, and the more advanced the pregnancy the closer the resem- 
blance. After-pains are not common until after the fourth month. 
Before that period they are usually due to incomplete expulsion of the 
products of conception. 

Involution takes place in less time than after labor at term. Subin- 
volution and the consequent metritis, however, are more common, owing 
to the neglect of the precautions usually observed after normal par- 
turition. 

Diagnosis. At first thought the diagnosis of abortion would seem to 
be an easy matter, but the practitioner will meet with no condition in 
his practice which at times will puzzle him to the same degree. In some 
cases the diagnosis is a simple affair. A woman who has always been 
regular passes one or two menstrual periods, then suddenly is seized 
with profuse hemorrhage, and on examination the cervix is found dilated 
and the finger comes into contact with a globular body — the ovum lying 
within it. Unfortunately, from a diagnostic point of view, such a com- 
bination of conditions is a rare exception. The first two condit ions may 
be met with, but on examination the cervix will he found closed and the 
uterus but slightly enlarged. The questions confronting the examiner 
then would be: (1) Has the woman been pregnant? (2) Has she 
aborted? (3) Is the abortion complete or incomplete? Amenorrhoea 
in a married woman who has always been regular and who is not nursing 
is strong presumptive evidence in favor of pregnancy. Other signs 
should be looked for. A uterus perceptibly larger than the non-gravid 
organ would confirm the diagnosis of abortion. The third question 
could be answered only by the presence or absence of hemorrhage, for 
with very few exceptions the hemorrhage will continue more or less 
irregularly so long as any portion or fragment of decidua or placenta is 
retained in the uterus. It is true that in some cases the presence of 
retained products within the uterus will be manifested by a patulous 
cervix, which will readily admit the index finger beyond the os inter- 
num, but the opposite condition, a closed cervix, obtains just as often. 

The occurrence of hemorrhage in the pregnant state is always signifi- 
cant of threatened or actual abortion. But such hemorrhage, more 
especially if it be slight, may be due to other causes. A visual inspection 
of the cervix with the aid of a speculum ought to be made to ascertain 
wmether the blood does not come from an erosion of the cervix, from 
carcinoma, or from a small cervical polypus. In some women there 
is a periodical flow for the first two or three months or more of 
pregnancy. 

Ectopic gestation may be mistaken for abortion. At times nothing 
but a careful bimanual examination (under narcosis if necessary) will 
serve to differentiate the two conditions. 

The points of distinction are: (1) The genital hemorrhage in ectopic 
gestation is more irregular and usually less profuse than in abortion. (2) 
The pain in ectopic gestation is generally more severe, and has the char- 
acteristics of severe colic more than of labor pains. (3) In ectopic gestation 
the patient is likely to suffer from syncopal attacks when rupture takes 
place, and at every recurrence of hemorrhage into the peritoneal cavitv. 



350 PATHOLOGY OF PREGNANCY. 

(4) The mass formed by an ectopic sac is, as a rule, much more sensitive 
to pressure than an imprisoned gravid fundus uteri. 

It occasionally happens that the gravid uterus enlarges irregularly on 
account of adhesions or of chronic metritis. As this condition is likely 
to lead to abortion sooner or later, it may give rise to the erroneous 
diagnosis of ectopic gestation (Vineberg 1 ). 

In very obscure cases, seeing that symptoms of abortion are present, 
there can be no objection to fully dilating the uterus under narcosis and 
exploring its cavity with the finger. 

Prognosis. The menace to life in spontaneous abortion is very slight, 
but abortion is often the starting-point of serious trouble. 

The dangers are : 

(a) Hemorrhage : Although this is seldom so severe as to endanger 
life, yet the woman may be markedly weakened by the loss of blood, 
which may persist for weeks if not arrested by proper treatment. 
Occasionally, however, it may be so profuse as to cause death (Zweifel 2 ). 

(6) Subinvolution : This may result in chronic metritis and endome- 
tritis, which may lead to invalidism. 

(c) Septic infection: This rarely occurs from retained products unless 
the woman has been examined by unclean hands, or had an unclean 
instrument passed into the uterine cavity. In the writer's experience, 
however, abortion in sharply retroflexed uteri is rather prone to be at- 
tended with septic infection. This, no doubt, is due to the circumstance 
that drainage is very markedly interfered with. Sepsis following abor- 
tion is not, as a rule, so serious a condition as that following labor at 
full term. On promptly emptying the uterus the septic manifestations, 
as a general rule, readily subside. An exception, however, must be 
made in cases of sepsis following criminal abortion. Here the course 
of the affection may be virulent and rapidly fatal. 

Treatment. Prophylactic. In order to succeed in the preventive 
treatment a very thorough investigation must be made of each case with 
a view to ascertaining the cause, and the treatment suitable for the con- 
dition found must be instituted. 

If retroversion be present, a suitable pessary should be introduced 
after the uterus has first been replaced to its proper position. The case 
should be carefully watched, especially during the third month and the 
commencement of the fourth, when the fundus rises out of the pelvis. 

After this the pessary may be removed. Chronic endometritis and 
laceration of the cervix call for appropriate treatment, which, of course, 
must be carried out before conception takes place. When uterine adhe- 
sions are the cause careful massage and stretching of the adhesions, 
followed by suitably placed tampons, may be attended with success. 

The pelvic massage may be carried out even during pregnancy; the 
manipulations, of course, must be conducted with the greatest gentleness 
and caution. 

If syphilis be suspected — and in cases of doubt as co causation it is 
always wise to suspect it — both parents should be subjected to a long- 
continued course of antisyphilitic treatment, and in the mother the 
treatment should be continued during the whole pregnancy. 

1 H. X. Vineberg. New York Med. Journ., vol. lix. p. 785. 
a P. Zweifel. Lehrbuch der Geburtshiilfe, Stuttgart, 1895. 



ABORTIOX AND PREMATURE LABOR. 351 

Nervous diseases, such as chorea, etc., must be combated by the 
proper remedies. 

In cases of habitual abortion, without any ascertainable cause, the 
woman should be enjoined to remain in bed during the time when the 
menses would normally recur. The rest in bed should be absolute, the 
patient not being allowed to get up to void urine or feces. Emotional 
excitement of all kinds should be prevented. Zweifel 1 states that he 
has met with success in some cases by entirely interdicting sexual inter- 
course during the whole pregnancy. Some authors speak favorably 
of the internal administration of potassium chlorate. The writer has 
met with apparent success with this form of treatment in a few cases. 
The salt is administered in five-grain doses, freely diluted, three times 
a day, and is to be given during the whole period of gestation. It is 
said to act by diminishing uterine irritation and congestion, and also by 
increasing the oxygen of the blood in the mother (Sir J. Y. Simpson 2 ). 
Viburnum prunifolium has been highly lauded in habitual abortion by 
E. W. Jenks. 3 He advises from a half teaspoonful to a teaspoonful of 
the fluid extract four times a day, beginning at least two days before 
the menstrual date, and continuing it for two days longer than the 
periods usually last. Pregnant women in whom the habit of abortion 
exists should not be allowed to go on long railroad journeys, nor on a 
sea voyage. In these cases it is best that at least a year elapse after the 
last abortion before pregnancy again occurs. Physiological rest of the 
sexual organs for a long period occasionally has a happy effect. 

Treatment of Threatened Abortion. The abortion may be arrested so 
long as the death of the ovum has not occurred. But as it is next to 
impossible to determine this point, we are forced to act, in great measure, 
empirically. If the hemorrhage has been moderate, more particularly 
if the cervix has not yet dilated to any extent, we should direct our 
efforts to staying the threatening event. 

It is rarely that we will meet with success after dilatation of the 
cervix to the extent of admitting the index-finger has taken place. 
Still, even with this degree of cervical dilatation our efforts may occa- 
sionally be rewarded by seeing the process arrested, the cervix close 
again, and the gestation go on to full term. 

The patient must be put to bed in a cool, darkened room and absolute 
rest enforced. She should not be allowed to sit up for any purpose what- 
soever. The diet should be bland and cool. No one but the nurse and one 
other attendant should be admitted into the sick-room. The remedy 
which forms the sheet anchor in this class of cases is opium in some form. 
A good way of administering it is in the form of rectal suppositories, each 
containing one grain of the aqueous extract. One may be slipped into 
the rectum every four or six hours. If, when first seen, the patient is 
suffering severe pain it is good practice to administer at once a hypo- 
dermic injection of morphine (gr. one-sixth to one-fourth). Viburnum 
prunifolium in half-drachm or drachm doses every six or eight hours 
acts as a sedative to the uterus and constitutes a valuable adjunct to the 
opium treatment. If the hemorrhage is profuse the patient's hips should 

1 P. Zweifel. Lehrbucb dcr Geburtshulfe, Stuttgart. 1895. 

2 Sir J. Y. Simpson. Obstet. Memoirs, Edinburgh, 1865, vol. i. p. 460. 

3 E. W. Jenks. Trans. Amer. Gyn. Soc., vol. i. p. 130. 



352 PATHOLOGY OF PREGNANCY. 

be elevated by a couple of pillows, and cold cloths cautiously applied to 
the vulva. The application of ice-cold cloths to the hypogastriurn is not 
advisable, owing to the danger of exciting uterine contractions. The same 
objection applies to the employment of vaginal tampons or gauze packing. 

The foregoing treatment should be continued until all hemorrhage and 
pain have entirely disappeared for at least two days. Great caution 
should be exercised after the cessation of the symptoms in allowing the 
patient to be up and about, or to resume her duties. On the reappearance 
of the slightest discharge of blood or on the return of the pains, the 
patient should .be made to go back to bed at once. 

When the threatened abortion is due to the incarceration of the fundus 
below the promontory, the patient should be placed in the knee-chest 
position and the cervix and vaginal vault exposed by lifting up the pos- 
terior vaginal wall with a good-sized Sims's speculum. The cervix is 
then caught with a tenaculum and gently drawn forward and down- 
ward while pressure is made against the fundus in the proper direction 
with a large wad of cotton held in an ordinary uterine dressing -forceps. 
In the majority of cases the manoeuvre will succeed in releasing the 
fundus and making it clear the promontory. A couple of large, firm 
tampons should then be placed in the posterior vaginal fornix to main- 
tain the fundus in the proper position. It may be necessary to repeat 
this treatment daily for several days, until all danger of the fundus falling 
back into the faulty position has disappeared. The patient need not 
necessarily stay in bed. 

Treatment of Inevitable Abortion. When, in spite of the foregoing 
treatment, the symptoms persist and the abortion becomes inevitable, 
or when the case at the outset shows evidences that it would be useless 
to attempt to arrest the process, our plan of treatment must be different. 
There is no further need of keeping the patient under so rigid restric- 
tions. 

The treatment of actual abortion still seems to be a disputed field. 
Some authorities (Diihrssen, 1 Fehling 2 ) strongly urge active interference 
at once. Others (Lusk, Winckel) favor an expectant plan of treatment, 
and would only interfere as necessity arises from hemorrhage or sepsis. 
It is the writer's custom to follow a course of action which lies about 
midway between these two apparent extremes. 

For the purposes of treatment it is well to divide the cases into early 
abortion (before the tenth week) and late abortion (from the tenth to the 
sixteenth week). 

When called to a case of early abortion, and there is evidence that the 
ovum has already escaped, and there is but a slight flow of blood which 
has lasted but a few days only, we can afford to wait a day or two longer 
to see whether the hemorrhage will entirely cease of itself. Of course, 
there must be an entire absence of febrile symptoms. The patient should 
be kept in bed, and the administration of ergot (sss t. i. d.) is advisable. 
While the total expulsion of the ovum and its membranes en masse is 
an exceptional occurrence, still in a fair proportion of the cases in which 
the ovum breaks through its envelopes and is expelled alone or with a 
portion of the decidua the remaining portions of the decidual residua 

1 Diihrssen. Archiv f. Gvn., Bd. xiii. Heft 2, S. 161. 

2 Fehling. Archiv f. Gyn., Bd. xiii. S. 222. 



ABORTION AND PREMATURE LABOR. 353 

are cast off either by uterine contractions or with the scant lochial secre- 
tions that follow. 

In the same class of cases, if the hemorrhage be profuse, or even if 
it be scanty, but has continued now and then for several days, the proper 
course to pursue is to curette without further delay. In these cases, as a 
rule, the hemorrhage is due to retained decidua which is firmly adherent 
to the uterine tissue, and no amount of uterine excitants will stimulate 
the uterus to such a degree as to enable it to extrude the decidua. It is 
just in these early cases that it is often difficult to know whether the 
ovum has already been cast off or not. When in doubt in this regard 
it is good practice to decide in favor of curettage at once. 

The operation when properly done — and every practitioner ought to 
know how to do it properly — is so free from danger and accomplishes 
the object in view so satisfactorily that the benefit of the doubt may be 
cast in its favor. The facts should always be plainly stated to the 
patient, and if she elects to wait to see what nature (perhaps with ergot) 
will accomplish, she must do so on her own responsibility. During 
the waiting period, if the hemorrhage be at all profuse, the vagina 
should be tightly packed with iodoform gauze, which may be left in situ 
for twenty-four or forty-eight hours. It must not be forgotten that all 
contact with the interior of the vagina must now be carried out under 
strict aseptic or antiseptic precautions. 

In another class of cases, forming only a very small percentage, at the 
first examination the ovum is found enveloped in some of its membranes 
lying in the cervical canal. 

In some of these cases the ovum is easily removed by hooking the 
finger above it and drawing it down ; in others again, the external os is 
so rigid and unyielding that its lips may have to be cut before the ovum 
can be extracted. An ordinary placental forceps will at times prove 
very serviceable in seizing the ovum and twisting it off as one would an 
ordinary polypus. In the majority of these cases any further interference 
will be unnecessary. But if the hemorrhage should not promptly cease 
after the above procedure the uterus should be subjected to a thorough 
curettage. 

In a third class of cases there may be unmistakable evidence, in the 
circumstance that the uterus corresponds in size to the period of gesta- 
tion, that the ovum and all its membranes are still within the uterine 
cavity. Two courses are offered: (1) To anaesthetize the patient, forci- 
bly dilate the uterus with branching dilators, and thoroughly empty the 
uterus, be it with the fingers alone or with the curette alone, or with a 
combination of both; and (2) to pack the cervix and vagina with iodo- 
form gauze, and wait for twenty-four or forty-eight hours to see if 
nature will be able to complete the process. The author's custom is to 
adopt the first course, unless the patient strenuously objects to it. The 
objection that may be raised against this plan of treatment is that it 
usually necessitates reliance upon the curette alone, as it is not often 
that the cervix can be dilated to the extent that one or two fingers may 
be passed into the uterine cavity. Should any one, however, not have 
sufficient confidence in his skill to use the curette in this manner, the 
second course may be pursued in part. The packing can be made to 
serve the double purpose of arresting the hemorrhage and dilating the 

23 



354 PATHOLOGY OF PREGNANCY. 

cervix. After the lapse of twenty-four or forty-eight hours the cervix 
will usually be found to have undergone sufficient dilatation to admit 
one or two fingers, with which the greater part of the uterine contents 
may be removed. The gentle use of the curette will succeed in bringing 
away the remainder. The employment of any form of tents to dilate 
the cervix is unsafe and unreliable practice. 

A great deal of discussion has taken place as to the relative merits of 
the finger and the curette for emptying the uterus in abortion. It 
really matters little which is used, so long as the products of concep- 
tion are totally removed. In a great number of cases it is impossible 
to obtain such dilatation of the cervix as to admit the introduction of 
one's finger. On the other hand, even when the finger can enter the 
uterine cavity it is not often possible by this means to bring away all the 
contents. In these cases it is the writer's practice to remove as much as 
possible with the finger, and then to supplement it with the use of the 
curette, employing the finger from time to time to ascertain if there is 
still anything left behind. 

In late abortions the general line of treatment resembles more or less 
closely that just described. At this period, however, we do not meet 
with the same difficulty in determining in a given case whether or not 
the foetus has been expelled. It is no longer possible for it to escape 
without exciting the notice of the patient or the attendants. If the 
foetus be still within the uterus it is a good plan to pack the vagina with 
iodoform gauze, pushing as much of the gauze within the cervix as pos- 
sible, even should the hemorrhage be not profuse. The cervical and 
vaginal packing has the effect of exciting uterine contractions, bringing 
about cervical dilatations, while at the same time it forms a safeguard 
against the occurrence of hemorrhage. At the end of twenty-four hours 
the packing should be removed, and if the cervix be found dilated the 
uterus should be emptied with the patient fully anaesthetized. In extract- 
ing the foetus care should be taken not to tear the trunk away from the 
head, the delivery of which may occasion considerable difficulty. This 
accident, however, will happen at times, no matter how careful we 
may be. It is a good plan in these cases to depress the uterus with one 
hand above the symphysis, and thus fix the round ball-like body, while 
with the finger or fingers of the other hand in the uterus a hole is bored 
into the head, which thus being hooked into may be easily extracted. 
When it cannot be thus delivered it may be easily broken up with the 
fingers and removed piecemeal. In carrying out these manoeuvres care 
ought to be exercised not to lacerate the soft uterine walls, an accident 
that need never occur, and one which the author has never met with, 
although he has resorted to this course on several occasions. The secun- 
dines in the majority of cases can next be removed with the fingers in 
the uterus, being aided by the other hand above the pubis, with which 
the uterus is depressed and held in a steady position. When the secun- 
dines cannot all be removed in this manner, the interior of the uterus 
may be gently scraped with a large partly sharp curette — Munde's or 
Lusk's (H. J. Garrigues 1 ). 

If it be found that the foetus has already been delivered, but that the 
secundines are still retained, the latter should be removed at once in 

1 H. J. Garrigues. The Medical News, Nov. 6, 1897. 



ABORTIOX AND PREMATURE LABOR. 355 

the manner just described, without waiting for the occurrence of hemor- 
rhage or sepsis before interfering. If the cervix be not sufficiently 
dilated, forcible dilatation should be practised, either with the finger or 
a steel divulsor. 

In all cases after emptying the uterus its cavity should be thoroughly 
irrigated with plain sterilized water, lysol (1 per cent.), carbolic acid 
(2 per cent.), creolin (J per cent.), or corrosive sublimate (1 to 2000 
or 3000). When using the latter agent an irrigation with sterilized 
water should follow. The toxic effects of corrosive sublimate solutions 
are due not so much to absorption during the irrigation as to the fact 
tha't a certain amount of fluid always remains behind in the uterus and 
is in part absorbed before it can drain away. 

Septic infection : At all periods and in every stage of abortion where 
there are any indications of sepsis, as manifested by elevation of tem- 
perature and rapidity of the pulse, or by a too rapid pulse, the temper- 
ature remaining normal or only slightly above it, active interference is 
called for at once. A day's delay, or even one of several hours, may 
allow a mild sepsis to develop into one of a serious nature such as 
may be beyond our power to control. As a general rule, the sepsis 
that occurs in the course of an abortion is readily amenable to the 
proper treatment, which consists in emptying the uterus thoroughly, 
and following this up with irrigations along the lines already laid 
down. An exception to the above rule is the sepsis occasionally seen 
in criminal abortions, which may run as foudroyante a course as the 
severer sepsis following labor at full term. 

Should the symptoms of sepsis not subside completely under the fore- 
going plan of action, the uterine cavity should be irrigated again, and the 
irrigations be repeated every four, six, or eight hours, according to the 
severity of the case. It will also be necessary to dilate the cervix from 
time to time, as it has a strong tendency to contract, and thus interfere 
with free drainage. Packing the uterine cavity in these cases is abso- 
lutely to be avoided, and even a strip of gauze in the cervix to favor 
drainage is, in our opinion, a snare and a delusion. There still seems to 
be a fear lurking in the minds of some distinguished authorities (Lusk, 1 
Garrigues, 2 and others), that curetting a highly septic uterus will destroy 
the protective wall which nature forms, the so-called "granulation 
zone" of Bumm. 3 The fear is founded upon a supposed fact which 
does not in reality exist. The "granulation zone" was observed by 
Bumm only in the milder cases of sepsis, in the so-called cases of 
" putrid intoxication;" in the severe forms of infection no such protec- 
tive zone was seen, but the micro-organisms were found penetrating the 
whole thickness of the uterine wall and on the peritoneum. If Bunim's 
observations were to guide us in our clinical work we would refrain from 
curetting the mild cases of uterine sepsis, while in the severe forms they 
would constitute no contraindication, for we could not destroy that which 
did not exist. But as a matter of fact the cases in which a well-marked 
"granulation-zone" was observed were the very cases which had been 
curetted, and which were promptly benefited by the curettage. 

1 Wm. T. Lusk. The Amer. Journ. of Obstetrics, 1896, vol. xxxiii. 

2 H. J. Garrigues. The Medical News, Nov. 6, 1897. 

3 E. Bumm. Archiv f. Gyn., Bd. xl. Heft 3, S. S98. 



356 PATHOLOGY OF PREGNANCY. 

The patient from the outset should receive the general treatment 
usually applied to septic conditions following parturition at term, and as 
this is fully described in another part of this treatise, it will be unneces- 
sary to repeat it here. 

immature labor : The treatment of immature labor is the same as that 
for premature labor, which will receive attention later. There is probably 
a greater tendency for the placenta to be retained in the uterus than when 
pregnancy is interrupted at a more advanced period. If there be no 
hemorrhage, nor any elevation of temperature, and the pulse is normal, 
there is no harm in waiting twenty-four or forty-eight hours to see if the 
uterus will of itself be able to expel the placenta. But to tampon the 
uterus and vagina during this period, as recently recommended by Gar- 
rigues, 1 would seem to be an unsafe procedure and one likely to favor 
sepsis. If such a contingency arise in country practice much the safer 
plan is to remove the placenta mauually at once should attempts to ex- 
press it by Crede's method fail. 

The patient might be seized with a dangerous hemorrhage in the physi- 
cian's absence, which nii^ht prove disastrous before he could reach her. 
Beside, there is a prevalent prejudice among the laity that is not en- 
tirely unfounded against leaving the after-birth in the uterus for any 
length of time after the foetus has been delivered. 

Curettage. The operation of curetting the uterus may now be de- 
scribed. The description may be premised by saying that the same care 
in asepsis and antisepsis ought to be exercised in regard to it as to that 
of any major operation. It is only by making this a routine in every- 
day practice that infection can be averted in cases which have not already 
been rendered septic. The operation should not be followed by rise of 
temperature in a clean case, and when it is, we must, as a rule, assume 
that we have introduced the pathogenic germs. 

The patient should be placed upon a table in the lithotomy position. 
This can be attained by the various leg-holders in the market, or, in 
the absence of these, by twisting a sheet diagonally, tying one end around 
the thigh near the knee, making it pass over one shoulder and under- 
neath the other, and tying the other end around the opposite thigh, both 
thighs being flexed upon the abdomen. The vulva and surrounding 
parts should be thoroughly scrubbed with an ordinary hand-brush and 
with warm water and green soap. Shaving off the hairs of the vulva 
may or may not be done. It is the writer's practice to do it. The hands 
should then again be washed before undertaking to scrub the vagina, 
which ought to be done thoroughly but not roughly. A gauze compress 
held in uterine forceps serves this purpose very well, aided from time to 
time with two fingers of one hand. There is nothing better to reach 
all the corners and crevices of the vagina than the fingers, or the half 
hand when there is a wide orifice. The vagina and vulva are then freely 
irrigated with sterilized water, which may be followed by an irrigation 
with some antiseptic solution. The legs should now be covered with 
sterilized cotton stockings or, what answers just as well, sterilized pillow- 
slips, and sterilized towels be placed upon the lower part of the abdomen, 
over the buttocks, and beneath the nates; in short, every part in the 
immediate vicinity of the operating field except the vaginal orifice should 

1 H. J. Garrigues. The Medical News, Nov. 6, 1897. 



ABORTIOX AND PREMATURE LABOR. 357 

be covered with sterilized cloths. While this is being done by the nurse, 
the operator should again subject his hands to a thorough scrubbing and 
washing. A weight-speculum (Edebohls') retracts the posterior vaginal 
wall and exposes the cervix, which is seized with one or two volsellse. 
Xo traction should be made with these, their purpose being merely to fix 
and steady the uterus. With one of the branching dilators the cervical 
canal is gradually dilated. Hegar's cervical bougies or Hanks' steel 
dilators may first be used, and the dilatation increased by the branching 
instrument. In some cases the cervix is very rigid, and to overcome this 
considerable force will be required; in others again, the tissues are very 
friable, and here the greatest caution must be exercised, or a serious tear 
extending into the uterus may be readily inflicted. After obtaining all 
the dilatation possible within safe limits, an attempt may be made to 
introduce the index-finger of oue hand. The finger may be able to 
locate the situation of the retained products, and perhaps remove them. 
In this procedure the instruments should be removed and the uterus 
depressed with the other hand above the symphysis. 

In many cases it will be impossible to dilate the cervix so that the 
finger may be introduced, as has already been stated. In these the 
curette alone will have to serve our purpose, and the sharp instrument 
is the one we invariably employ. Very many object to the use of a 
sharp curette as being too dangerous, and recommend a dull one. It 
seems to us that less harm is likely to be done with a sharp than with a 
dull instrument, for we can gauge the necessary force to employ more 
accurately with the former than with the latter. It must be admitted 
that the uterus may be perforated with either instrument, even in skilled 
hands, but ill results need not necessarily follow. When it is learned that 
the accident has occurred, the remainder of the uterus may still be 
curetted, care being taken to avoid the point of injury, and no irrigation 
should be employed. Should any inflammatory reaction follow, an ice- 
bag may be placed over the lower part of the abdomen and opium 
suppositories administered. There is no excuse for some of the serious 
accidents that are occasionally reported. They are not inherent in the 
operation, but are due to a combination of brute force and gross igno- 
rance on the part of the operator. 

The three accidents reported by M. D. Mann 1 were due not to the 
use of the curette, but to the branching dilator, which in two of the 
cases evidently perforated the uterus when being introduced, and the 
perforations were increased in size by introducing forceps which seized 
coils of intestine. In Mann's 2 own case the tear in the uterus was 
effected with Goodell's dilators. Still he thoroughly curetted the uterus 
after the accident, and the patient made a good recovery. Why these 
cases should be used as a warning against the use of the curette, as Mann 
seems to imply, it is difficult to understand. 

Injury to the uterus in curetting is more frequently inflicted by push- 
ing the curette through the uterine wall than in the act of scraping. 
By bimanual examination the size of the uterus, and consequently the 
depth of its cavity, can be fairly well estimated. By this means also the 
direction of the canal can be ascertained. In introducing the curette, 
therefore, one ought to know in which direction to carry it and when it 

1 M. D. Mann. The Amer. Journ. of Obstetrics, 1895, vol. xxxi. p. 603. - Ibid. 



358 PATHOLOGY OF PEEGXAXCY. 

may be expected to reach the fundus. No force whatever should be 
employed in this manoeuvre. 

Having passed the curette to the fundus the wall is scraped on with- 
drawing it, and one soon learns in which region of the uterus the retained 
products are situated. The curetting at this point may be done more 
vigorously, but a close watch must be kept upon the nature of the tissues 
removed. With a little experience one readily learns when the curette 
has reached the harder uterine tissue. In cases in which the uterus is 
very soft, the instrument, if a sharp one, need merely to be gently drawn 
over the surface. AVhile the curette is being used, it is a good plan 
to apply one or two fingers of the other hand through the vaginal 
wall against that portion of the uterus which is being scraped internally. 
This steadies the wall of the uterus and aids us to gauge the force to 
employ. It is particularly in the cornua that decidual and placental 
residua are likely to be retained. These regions of the uterus, there- 
fore, call for especial attention. When the operator feels satisfied that 
everything has been removed, the uterine cavity should be irrigated as 
stated above, but packing the uterus or the vagina with gauze ought to 
be avoided except in those instances in which uncontrollable hemorrhage 
follows the operation. 

It is a good plan to administer ergot for the following four or five 
days or longer, in order to favor involution. The patient should be kept 
in bed for six or seven days, at the end of which time the uterus should 
be examined bimanually to ascertain if involution has progressed satis- 
factorily. 

Missed Abortion and Missed Labor. 

Missed Abortion. It occasionally happens that the foetus dies and the 
progress of gestation ceases, but the products remain within the uterus 
for weeks or even months. To this phenomenon the term te missed 
abortion" is applied; a similar condition occurring when pregnancy has 
arrived at full term is called " missed labor." 

Missed abortion must also imply a comparatively quiescent state of 
the uterus, in order to distinguish it from prolonged abortion (W. Japp 
Sinclair 1 ). 

As a rule, at the time of the death of the foetus a slight hemorrhage 
occurs; but this may be absent, as it was in the three cases reported by 
Sinclair. It is seldom necessary to interfere manually in these cases. 
According to Sinclair, 2 " missed abortion" does not occur among young 
and presumably vigorous primiparse. The writer's patient was young, 
but of rather delicate build, and had mitral stenosis. The same autho- 
rity states that there is seldom a history of previous abortions or reten- 
tions in these cases ; in our case there had been. 

Missed Labor. In this condition there may or may not be some of 
the phenomena of ordinary labor at the time parturition should nor- 
mally occur. If they do occur, the pains and the discharge are very 
slight, and soon cease. 

The fate of the retained child varies very much. In some instances 
when the membranes are not broken and no atmospheric air enters the 
amniotic cavity, the foetus may remain fresh for a long time ; in others 

1 W. Japp Sinclair. Brit. Gyn. Journ., 1887-'88, p. 201. 2 Ibid. 



ABORTIOX AND PREMATURE LABOR. 359 

it becomes macerated and undergoes mummification. In other cases 
again, when atmospheric air does enter the cavity, putrefactive changes 
set in, giving rise to the condition known as physometra. Sometimes 
the soft parts of the foetus disappear through liquefaction, and the bones 
are a long time in being discharged; sometimes they pass through the 
uterine walls and appear in the vagina, rectum, or bladder, or they set 
up in their passage an inflammatory process about the uterus, leading to 
a pelvic abscess. 

It is generally recommended to wait a few weeks in cases of missed 
labor, in the hope that the uterine contents may come away of themselves 
without artificial interference. Should this plan be pursued the patient 
ought to be carefully watched, and on the slightest manifestations of 
fever or symptoms of sepsis the uterus should at once be emptied of its 
contents. One should always decide in favor of artificial interference as 
soon as there is positive evidence of the death of the foetus. The woman is 
exposed to less risks by the adoption of this plan of procedure, carefully 
conducted, than she would be by carrying about a dead foetus for an 
indefinite period. 

In every case after the delivery of a dead foetus, it is a good plan to 
follow the expulsion of the placenta and membranes with a copious 
intra-uterine douche of some mild antiseptic solution. 

The administration of ergot for some days after the emptying of the 
uterus is particularly advisable, as the uterus in these cases has a tendency 
to inertia and retarded involution. 



Premature Labor. 

The factors already stated as being causative of abortion may like- 
wise act at a later stage of gestation, and be the means of prematurely 
terminating the pregnancy. 

The most common causes, however, are faulty insertion of the placenta, 
albuminuria, and syphilis. 

In 357 cases analyzed by Vallais 1 faulty insertion of the placenta was 
present in 179 cases, albuminuria in 39 cases, and syphilis in 33 cases. 
In 82 cases no cause could be ascertained. 

Treatment. When a woman is threatened with premature labor and 
the foetus is still alive, one would naturally endeavor at first to avert it, 
unless there were marked albuminuria and threatening symptoms of an 
eclamptic seizure, or in the presence of a faulty insertion of the placenta 
(placenta prsevia and placenta marginalis) ; in such contingencies one 
would, on the contrary, hasten the event. Opium must now be given 
with some caution, for fear of its unfavorable effect on the foetus. A 
combination of potassium bromide and chloral hydrate (aa gr. xv.) acts 
well in these cases. Should one's efforts fail and the labor go on 
progressing, its management is precisely similar to that of labor at terin, 
and hence does not call for special attention here. 

Frangois Vallais. These, Paris, 1893. 



CHAPTER XVII. 

ECTOPIC GESTATION. 

Definition. When an impregnated ovum becomes fixed and begins to 
develop outside of the uterine cavity, ectopic gestation or extra-uterine 
pregnancy is established. 

Varieties. The classification of ectopic gestation into tubal, ovarian, 
and abdominal, made by Biauchi in 1741, and simplified by Boehmer in 
1752, remains practically unchanged, as far as the primary forms are 
concerned, unto this day. The terms primary and secondary, as applied 
to ectopic gestation, refer to the conditions before and after rupture or 
change of location of the ovum. As will hereafter be shown, rupture 
and change of location occur in the majority of cases, the anatomical 
relations of the ovum to its surroundings being thereby altered. Cases 
of primary ovarian and abdominal gestation are so rare and so difficult 
of absolute demonstration, that the general statement may be admitted 
that every ectopic pregnancy is primarily tubal. 

Tubal pregnancies are classified according to the site of attachment of 
the ovum as (1) interstitial, the so-called tubo-uterine; (2) true tubal, 
isthmial, or ampullar, and (3) infundibular or tubo-ovarian. 

1. Interstitial Pregnancy refers to that class of cases in which the ovum 
develops in that portion of the tube which passes through the wall of the 
uterus, or in a diverticulum from that part of the tube. 

2. True Tubal Pregnancy is the variety in which the ovum develops 
in the free portion of the tube, without protrusion into either the uterine 
or the abdominal cavity. When it occurs in the inner portion of the 
tube, it is termed isthmial, and when in the outer, ampullar. 

3. Infundibular Pregnancy includes the cases in which the ovum is 
lodged and developed in the infundibulum of the tube, and prevents 
closure of its abdominal ostium. The cases of this variety in whicji the 
ovum is attached to the ovary are ordinarily styled tubo-ovarian. 

Ovarian and Abdominal Pregnancy are terms applied to those cases of 
extra-uterine pregnancy which are supposed to originate and develop in 
the ovary or in the abdominal cavity. 

Anomalous Varieties. Ectopic pregnancy may occur in an accessory 
fimbriated extremity (see Fig. 235), or in a diverticulum from the Fallo- 
pian tube (see Fig. 236). Both of these varieties are to all intents and 
purposes tubal pregnancies. 

Cornual Pregnancy occurs when the seat of gestation is in the undevel- 
oped horn of a bicornate uterus. This anomaly is due to unequal devel- 
opment or lack of proper union of the two Mullerian ducts. Although 
cornual pregnancy in its course and termination resembles extra-uterine 
pregnancy, it cannot properly be classed as a variety of the latter, but 
is a true uterine pregnancy, which, by reason of the malformation of the 
organ, eventually becomes pedunculated and walled off from the main 

(360) 



ECTOPIC GESTATION. 



361 



cavity. It is, however, surrouDded by uterine mucosa, and the decidua 
is formed in the impregnated cornu. 

Any attempt to classify the secondary forms of extra-uterine pregnancy 
leads to confusion. In this connection the term secondary means subse- 



Fig. 235. 




Ectopic gestation in blind accessory fimbriated extremity of right tube. 
Fig. 236. 




Left Fallopian tube with ectopic gestation in diverticulum. 
a, a. Gestation sac communicating with diverticulum. 

quent to rupture or displacement. When an ovum breaks through its 
outer investing structures without rupture of the sac, its development 
is not necessarily arrested, although its anatomical relations may be 



362 



PATHOLOGY OF PREGNANCY. 



changed. A special name has been given to each of the varied locations 
of the displaced ovum, and to this fact is due the confusion of terms. 



Fig. 23*3 



Fig. 238. 




Fig. 239. 




Sections made from case represented in Fig. 236 on each side and at extremity of diverticulum. 
They show distinctly the separate canals and the narrowing of the diverticulum as it approaches 
the uterus. 

a, a. Lumen of main canal of Fallopian tube, b, b. Lumen of diverticulum. 

The secondary forms are simply complications of the primary varieties 
before described, and are not deserving of separate classification. The 



ECTOPIC GESTATION. 363 

various names applied to these forms are in so common use, however, 
that they can hardly be iernored. They will, therefore, be mentioned 
later. 

Etiology. The point at which the spermatozoa meet and impregnate 
the human ovum is not definitely known. That the spermatozoa pass 
through the lumen of the Fallopian tube with ease is a fact, and it 
is very probable that in man, as in other mammalia in which this 
observation has actually been made, impregnation occurs in this 
location. 

The habitual ease with which spermatozoa pass from the orifice of the 
vagina through a virgin os uteri, oftentimes occluded by mucus, into the 
uterus, and the occasional cases in which, despite frequent disturbance, 
they travel from outside the vulva, through an almost imperforate hymen, 
up a vagina containing secretions destructive to their life, and finally pass 
uninjured into the uterus, make it reasonable to suppose that they may 
go with not less ease up the uterus into the Fallopian tube, and even 
into the abdominal cavity. There is no reason to believe that the cili- 
ated epithelium of the tube, which assists the migration of the ovum 

Fig. 240. 




a 

Left Fallopian tube with diverticulum reconstructed, 
a, a. Diverticulum. 

toward the uterus, obstructs the progress of the spermatozoa, nor is it 
probable that the peristaltic action of the tube toward the uterus would 
check the march of so minute a body as a spermatozoon. 

In the lower animals the presence of spermatozoa in the pelvic cavity, 
as well as in every portion of the genital tract, soon after coitus, has 
been repeatedly demonstrated. Moreover, the migration of the ovum 
in the human female has apparently been proved by the occurrence of 
pregnancy in patients in whom the ovary of one side and the tube of the 
opposite side had been removed. If this migratory range for both ovum 
and spermatozoa be admitted, the mechanical theory of ectopic gestation 
is thereby made reasonably plain. The inference would be, however, 
that such gestation would be more common, and primary abdominal 
pregnancy the most frequent form. This, we know, is not a fact, for 
even the existence of this latter variety can hardly be established. 

There is then something characteristic of the tubal mucosa which 
allows the implantation and growth of a fertilized ovum or some element 
that inhibits its growth or destroys it in the pelvic cavity. Clarence 



364 PATHOLOGY OF PREGNANCY. 

Webster explains this by claiming that, beside the mechanical condition 
which retains the ovum, there is need cf " the occurrence of certain 
necessary reactions in the mucosa, caused by genetic influence and pro- 
ducing decidual changes, such influence existing by reason of a reversion 
in the tubal mucosa to an earlier type in mammalian evolution. " 

A pathological condition of the ovum may favor a premature adhesion 
to the wall of the tube before the uterine cavity is reached. Pathological 
or abnormal conditions of the tube itself, however, form undoubtedly 
the most important factor in the causation of. ectopic gestation. Chief 
among these may be mentioned the following: Congenital deviations from 
normal type, such as exaggerated convolutions (Fig. 241), diverticula 
(Figs. 236 and 241), and atresias ; sagging and attachments by adhe- 
sion, resulting in distortion of the tube; pressure from adjoining organs; 
thickening of tubal Avails, either congenital or acquired, diminishing 
peristalsis; desquamative salpingitis or hyperplasia, destroying the cilia, 
producing atresia; growths, either in the canal or the walls; obscure 
conditions, preventing coaptation of the fimbriae with the ovum or ovary. 

Fig. 241. 



Infundibular ectopic gestation with Fallopian tube, showing exaggerated convolutions. 

Herzog, in a recent article on " The Pathology of Tubal Pregnancy," l 
concerning this subject, says : 

" The etiology of tubal pregnancy is certainly not a uniform one for 
all cases. It appears to me that in a respectable percentage of cases 
congenital anomalies of the tubes due to anomalies in early embryonic 
development of the Mullerian ducts are responsible for the occurrence 
of tubal pregnancy. I have previously, conjointly with Dr. F. Hen- 
rotin, reported cases of tubal pregnancies due to tubal anomalies. 

" Another factor which I consider as important in the production of 
tubal gestation is an unduly marked participation of the tubal mucosa 
in menstruation. With others I hold that the tubal mucosa takes part 
to a certain extent in menstruation. Normally the menstrual changes 
of the tubal mucosa are insignificant compared with those of the uterine 

1 Amer. Jour, of Obstet., 1900. 



ECTOPIC GESTATION. 365 

mucosa. Occasionally, however, the tubal mucosa shows intense men- 
strual changes, which may be so pronounced as to lead to the formation 
of a hematosalpinx. We can hardly doubt that the menstrual changes 
of the uterine mucosa prepare the latter for the reception of an impreg- 
nated ovum, which, as appears most probable from the latest contribu- 
tions upon the subject, eats or corrodes its way into the substance of 
the uterine mucosa by the aid of a phagocytic trophoblast. Whenever 
the tubal mucous membrane undergoes extensive menstrual changes it 
becomes a soil into which an impregnated ovum can easily implant 
itself. It appears, therefore, very probable that marked menstrual 
changes in the tubal mucosa, when they do occur — and they occasionally 
are present — become the cause of an ectopic implantation of a fertilized 
ovum. As far as our exact knowledge goes to-day, we must, however, 
coufess that we are unable in most cases of tubal pregnancy to give 
definitely the exact cause or causes of this event, often so very grave 
in its consequences." 

Pathology. Changes in the Uterus. This organ begins to enlarge, both 
as to its cavity and walls, simultaneously with the establishment of preg- 
nancy in the tube. It continues to enlarge, and up to the fifth month is 
usually one-third to one-fourth smaller than in an intra- uterine pregnancy 
of the same age. The enlargement may continue after this time, but at 
a less rapid rate. Rupture of the tubal pregnancy, when followed by 
death of the ovum, checks the growth of the uterus, and is soon followed 
by involution. When, however, death of the ovum does not take place, 
the uterus may continue to enlarge, though not to the same extent as 
before the accident. The uterus of an extra-uterine pregnancy at full 
term usually measures from four to six inches in depth. Involution of 
the uterus does not commence until the foetus is dead, and decrease in the 
size of the uterus is an indication that this has occurred. In general 
terms, it may be stated that the more remote the place of implanta- 
tion of the ovum from the uterus, the less the increase in size of that 
organ. 

Decidua. One of the most notable changes in the uterus in ectopic 
gestation is the formation of a decidua. It partakes of the characteris- 
tics of the decidua vera of normal pregnancy, and is usually thrown off, 
either in one complete cast or in the shape of debris, about the time of 
the primary tubal rupture, and this event is frequently accompanied with 
metrorrhagia. The casting off of the decidua may precede, accompany, 
or follow the rupture. The persistence of life in the ovum after primary 
rupture does not prevent the shedding of this membrane. The decidua 
varies in thickness from one-eighth to one-quarter of an inch, is rough 
and shaggy upon its uterine side and smooth upon its inner surface, and, 
of course, in the uterus shows no traces of decidua reflexa and decidua 
serotina (Fig. 242). 

Alterations and Changes in the Tube and Ovum. These vary 
greatly with the location of the gestation-sac, but swelling and turgescence 
are present in all cases from the beginning. This thickening consists at 
first in simple enlargement of the calibre of vessels due to the stimulus 
given by the existence of the pregnancy, then of hypertrophy of mus- 
cular fibre, the same as the first changes which take place in the uterus 
in normal pregnancy. Then follows the free development of connective 



366 



PATHOLOGY OF PREGXAXCY. 



tissue and often disappearance of muscular fibres, particularly following 
the evidences of minute rupture, which disintegrates and breaks them up 
by small extravasations and hemorrhages, and gives rise to inflammatory 



Fig. 242. 



^aa 





?J« 



Scrapings from the uterus in a case of ectopic gestation in the third month. 

a. Decidua vera. b. Decidua in the beginning of coagulation necrosis, showing many leucocytes. 

c. Blood sinus, d, d. Gland spaces. (Herzog.) 

and cystic changes ; or pressure-atrophy of the wall takes place opposite 
the placental attachment, which has become the thickest part of the tube. 

Closure of the ostium abdominale usually takes place about the seventh 
or eighth week when the oosperm is retained in the middle or inner 
portion. When, however, it is retained near the abdominal opening, 
complete closure does not occur, and there is, consequently, a tendency 
to tubal abortion. 

In the apparent exceptions to this rule in which the ostium is not 
closed at twelve weeks, examination of the specimen and careful analysis 
of the history usually demonstrate that rupture had taken place several 
weeks earlier. 

It appears that closure of the abdominal opening may also occur 
much earlier than the seventh or eighth week. The writer has operated 
on a case of tubal pregnancy in which, as was obvious from the history 
and from the microscopic examination of the specimen obtained, rupture 
occurred in the second or third week of gestation. In this case the 
abdominal opening of the tube was found closed. 

The formation of a decidua in the pregnant tube is now conceded by 
all competent observers. A number of my own cases have been exam- 
ined for that purpose, and a decidua has invariably been found (Fig. 
246). It has also occasionally been found in the opposite non-pregnant 



ECTOPIC GESTATION. 



367 



tube. The amount of decidua vera, however, varies considerably in dif- 
ferent eases, but in all instances the characteristics of the true decidua 



Fig. 243. 




Tubal pregnancy, 2-3 weeks old (natural size). 
a. Rupture and blood coagulum. b. Closed fimbriated extremity, c, Ovary. 

of uterine pregnancy are shown ; namely, the usual two layers, a super- 
ficial compact "and a spongy, lower layer. The enlarged vessels common 

Fth. 244. Fig. 245. 




■S 



Jt>**gf 



s k 



f 



Decidual cells in serotina; tubal pregnancy, 

2-3 weeks old. (Herzog.) 

From case represented in Fig. 243. 



Villus highly magnified, showing Langhans 
layer and syncytium. In the mesodermal core 
a blood-vessel with nucleated red blood-cor- 
puscles. (Herzog.) 

From case represented in Fig. 243. 



to the whole tube are particularly prominent in that portion of the 
mucosa covered by decidua to which the ovum becomes attached, and 
which is known as decidua serotina. This decidua serotina grows more 
rapidly than the rest of the decidua. 

At an early period in uterine gestation an intervillous space filled with 
maternal blood, bounded on the outside throughout most of its extent by 
the decidua reflexa, surrounds the whole chorion. In tubal pregnancy, 
therefore, there must also always be formed a decidua reflexa, because an 
intervillous space capable of retaining the maternal blood can be formed 



368 



PATHOLOGY OF PREGNANCY. 



only by a decidua reflexa, unless we assume that the tube very early 
becomes completely obliterated on both sides of the ovum. Since we 
have no proof of such a very improbable occurrence, a decidua reflexa 
becomes an absolute necessity for the establishment of the intervillous 
space (Herzog). 

Fig. 246. 




—_______- 



Section from gravid Fallopian tube. Lutz, Obj. 3 ; Eye-piece No. 3. 
A. Decidual cells. B. Villi. C. Syncytial buds cut transversely. D. Blood in intervillous space. 

Hemorrhages found in the tube are most frequently the result of rup- 
ture of the reflexal vessels. As pregnancy advances the decidual cells 
in the balance of the tube disappear, and inflammatory changes, the result 
of the minute ruptures, combined with possibly mild pre-existing septic 
conditions, change the general texture of the mass. The growth of the 
ovum stretches the lumen of the tube, which gradually becomes, together 
with the placenta and membranes, a part of the investing heterogeneous 
gestation-sac. 

But little can be said in this connection of the changes in the ovum, 
its development and attachment being made comparatively plain if the 
presence of a decidua is admitted, as it thus follows the transformations 
usual to a pregnancy in the uterus, subject simply to the changes incident 
to lack of space in the tubes, and the traumatisms which must almost 
inevitably result, and which will be considered when speaking of the 
different varieties. 



ECTOPIC GESTATION. 



369 



The true investing foetal membranes, namely, amnion and chorion, 
differ in no wise from the same structures in uterine pregnancy, but are 
also subject to the alterations incident to trauma and possible sepsis. 

Tubal Mole and Tubal Abortion. The subject of alterations in the ovum 
can hardly be dismissed without reference to that arrest of development 
during the first few weeks which results in what is known as a tubal 
mole. An ovum during its first few weeks of growth, depending as it 
does for life upon very delicate chorionic villi lightly attached, is in great 
and constant danger of destruction. In some cases, by reason of chori- 
onic hemorrhage, the circulation is cut off, the ovum is partially or 
totally detached, remains in situ and is absorbed, or, after detachment, 
particularly when located in the outer third of the tube, it may be ex- 
pelled through a patent ostium abdominale into the abdominal cavity. 
This constitutes what is known as a tubal abortion. Sometimes, how- 
ever, the tube ruptures and the mole is extruded directly into the free 
cavity, often with most appalling symptoms. 

It cannot be stated definitely that subperitoneal rupture does not occur 
in these early cases, for no observations bearing upon this point have, so 
far as the writer knows, been absolutely demonstrated. The proof of 
this condition must depend upon the report of a competent pathologist 
after thorough dissection. 

A Tubal Mole resembles a blood-clot in color and consistence, is 
round or ovoid, and from two to six centimetres in diameter (Fig. 
247). It usually presents, on section, a smooth-walled cavity, lined with 
amnion, occasionally containing foetal remnants. Both amniotic cavity 
and foetal remnants may be absent, but the presence of chorionic villi 
makes the origin manifest. Bland Sutton believes that a tubal mole 
"is due to blood extra vasated from the circulation of the embryo into 
the subchorionic chamber." 



Fig. 247. 




Tubal mole, fifth week. 
a. Mole protruding from ruptured portion of tube. B. Ostium abdominale partially closed by 

infolding of the fimbriae. 



Changes in the Placenta. In no case of tubal pregnancy is there 
absence of decidual formation, but there is a marked difference in differ- 
ent cases as to the extent to which this membrane is formed. Observations 

24 



370 PATHOLOGY OF PREGNANCY. 

by a number of modern competent observers, looking toward an eluci- 
dation of this question, demonstrate the almost constant presence of 
decidual membrane in the tube. Taking this for granted, the placenta, 
as in uterine pregnancy, is composed of loosely held masses of chorionic 
villi with intervillous blood-spaces bounded externally by varying areas 
of decidua serotina. The development of this organ is necessarily mod- 
ified by the amount of decidua present. When to this is added the nar- 
rowed available space still further constricted by the rugosities of the 
mucosa and the mobility of the tube, the difficulties in the way of the 
development and growth of the placenta can readily be appreciated. 

When, however, rupture occurs, and the torn walls of the tube spread 
out, if the ovum survive, the placenta forms further attachments to 
neighboring structures and continues its growth. The size of placentas 
varies directly with the vascularity of the structures upon which they 
become implanted and with the permanence of the attachment. From 
the beginning the essential elements of disturbance in the development 
of the placenta are traumatic hemorrhages. The tube wall early in preg- 
nancy cannot, as a rule, accommodate itself to the growing ovum. It 
becomes stretched, and ruptures take place into the substance of the 
serotina, accompanied by hemorrhage into the intervillous space, endan- 
gering the integrity of villi and chorion. 

When an ectopic placenta is examined at any period of gestation, 
evidences of previous hemorrhages are rarely absent. These hemor- 
rhages are necessarily small while the mass is confined within the tube, 
but after rupture they may be severe and even fatal. The fatal termi- 
nation is, however, ordinarily due to what may be termed. " detachment 
hemorrhages 7 ' — that is, hemorrhages from maternal vessels consequent 
upon detachment of the placenta. 

Independent of detachment hemorrhages, however, are the constantly 
recurring extravasations into the serotinal tissue. These intraplacental 
hemorrhages materially increase the bulk of the placenta, and produce 
an apparent disproportion between its size and that of the ovum. This 
disproportion is the foundation for the erroneous statement that the 
growth of the placenta continues after the death of the ovum. It is 
very possible that an intraplacental hemorrhage may increase somewhat, 
but it is hardly reasonable to suppose that the formation of true placental 
tissue could continue, and this has never been demonstrated. The chori- 
onic villi degenerate and become in a very short time mere phantoms 
with indistinct outlines. New formation of villi is most improbable. 
The decidua serotina also undergoes rapid degeneration. Therefore, no 
real growth of placental tissue can occur after the death of the foetus; if 
an increase in size takes place it must be due to traumatic hemorrhages. . 

The placenta is then transformed from an oval or round disk to a more 
or less globular mass, which, upon careful examination, is seen to be com- 
posed of blood-clots in various degrees of organization, with deteriorated 
villi interspersed, and a large number of leucocytes, and to contain no 
more than the normal amount of true placental tissue. In case of very 
old placentas, indeed, so marked an alteration has occurred that little 
normal placental tissue can be recognized. 



ECTOPIC G EST AT 10 S. 371 

Symptomatology and Diagnosis. 

A. Prior to the Fourth Month. 

General Considerations. Prior to the fourth month the three cardinal 
and practically constant points in the diagnosis of beginning extra-uterine 
pregnancy are (1) disturbance of menstruation, (2) sharp pelvic pain, 
usually accompanied with faintness, and (3) the presence of a mass 
adjacent to and connected with the uterus. Certainty of diagnosis is 
based upon a logical analysis of these three factors. 

1. Disturbance of Menstruation. Menstruation is almost always retarded ; 
but the variations as regards the amount, character, and periodicity of the 
hemorrhage are so numerous as to render the description of a typical case 
difficult. In some cases uterine hemorrhage occurs a day or two follow- 
ing the date of the expected menstruation; in other cases amenorrhcea 
persists throughout the pregnancy; the flow may continue for two or 
three days, and may recur with sufficient regularity to simulate menstru- 
ation, but this is exceptional. The first day of the flow is seldom or 
never the twenty-eighth day after the beginning of the last menstruation. 
Sometimes the flow continues for a day or two, and then recurs at irreg- 
ular intervals; but in other cases the hemorrhage persists for weeks at a 
time. The amount of blood lost also varies greatly, from a mere show 
to a severe hemorrhage. The blood usually contains small patches of 
mucosa or large, well-defined membranes, and occasionally a complete 
cast of the lining of the uterus. These hemorrhages, regular or irregular, 
occurring early in ectopic gestation, usually indicate shedding of the 
decidua. 

2. Pelvic Pain. The pain is usually of two kinds: the recurrent, con- 
tractile pain due to uterine contractions, and the sharp, tearing pain, 
accompanied with faintness, which indicates rupture to a greater or less 
degree. Excruciating pain with syncope usually points to serious rupture. 

3. Presence of a Mass. When the pregnancy is located in the middle 
or at the outer end of the normally situated tube, and is unruptured, a 
well-defined movable mass, contiguous to the uterus, can be felt. When 
the tube is prolapsed posteriorly, the mass will be felt posterior to the 
body of the uterus. After rupture into the broad ligament has taken 
place the mass can still be felt lateral to the uterus, but it is lower, not 
so well outlined, and less movable. When sepsis has supervened, the 
presence of exudate may render the outlining of the mass still more 
difficult. In interstitial pregnancy the mass appears as an irregular 
bulging at the corner of the uterus. When early rupture into the gen- 
eral peritoneal cavity has occurred, no mass may be felt at all. 

The nausea ; changes in the breasts, and discoloration of the vaginal 
mucosa are confirmatory of the diagnosis of pregnancy, and, when com- 
bined with the signs detailed above, are strongly presumptive of extra- 
uterine pregnancy. Valuable corroborative evidence is furnished by the 
changes in the uterus, and by uterine hemorrhage when it occurs. The 
adjoining pregnancy stimulates the growth of the uterus, but not to 
the extent which obtains in uterine gestation of the same age. This dis- 
proportion in size becomes more marked as pregnancy progresses. Uter- 
ine hemorrhage frequently occurs before the third month of extra-uterine 



372 PATHOLOGY OF PREGNANCY. 

pregnancy, and is usually accompanied with the discharge of decidua, 
which, as mentioned before, is cast off either in shreds, in large patches, 
or as a complete cast of the uterine cavity. The absence of chorionic 
villi after careful search furnishes another link in the chain of evidence. 
At this stage of the investigation exploration of the cavity of the uterus 
is warrantable. When, after careful introduction of a sound into the 
uterine cavity, the uterus is adjudged empty, the diagnosis of early ectopic 
pregnancy is practically established. 

Primary Intraperitoneal Rupture — Hematocele. In the great majority 
of cases, gravid Fallopian tubes rupture prior to the fourth month. This 
is known as primary rupture, to distinguish it from subsequent ruptures 
which may occur in the same pregnancy. Primary rupture may be intra- 
or extraperitoneal. Experience demonstrates that primary intraperitoneal 
ruptures generally occur prior to the seventh week, and so frequently in 
the fifth or sixth week after the last menstruation that pregnancy is not 
suspected. As women with pre-existing pelvic disease are especially 
prone to extra-uterine pregnancy, menstrual irregularities easily escape 
attention. 

The diagnosis of primary intraperitoneal rupture prior to the seventh 
week is the diagnosis of intra-abdominal hemorrhage. The absence of 
marked disturbance of menstruation does not preclude the existence of 
early rupture. The failure to observe the discharge is not significant, 
for this may occur simultaneously with the rupture, or may closely follow 
it. The physical signs are identical with those of intra-abdominal hem- 
orrhage. 

The case illustrated by Figs. 243, 244, and 245, though extremely rare 
and the only one of its kind on record, shows the difficulty of diagnosis 
when reliance is placed on some retardation of menstruation. In that 
instance the patient had menstruated regularly for years, and pregnancy 
occurred, followed by rupture both within four weeks and before the time 
for the next period to make its appearance. 

The failure to recognize a tumor near the uterus is not very important. 
Thorough examination is difficult on account of the condition of the 
patient. Even when the intra-abdominal hemorrhage is enormous, the 
chief reliance must be placed upon the general conditions of shock and 
collapse, as the presence of blood can seldom be demonstrated by fluctua- 
tion, abdominal palpation, or bimanual examination. A symptom rarely 
absent, however, is exquisite general abdominal tenderness. The ovum 
may be so small as to produce no appreciable enlargement, or it may 
have been expelled into the general peritoneal cavity. 

The following case furnishes an excellent illustration of the symptoma- 
tology of primary intraperitoneal rupture. 

On September 15, 1894, Mrs. J. P. C. was seized with a severe pain 
in the abdomen, which she described as feeling " like something break- 
ing in her stomach." Simultaneously there was a gush of bright, pink- 
ish, watery fluid from the vagina, which flooded her thighs and saturated 
her clothing. She was seen by a physician at 1.30 p.m., and by another 
an hour later, and at 5.30 by the writer. At that time she was almost 
in articulo mortis, and absolutely pulseless and perfectly cold. The 
patient was thirty-three years of age, had been married twelve years, 
and had three children, aged, respectively, ten, five, and three years. 



ECTOPIC GESTATION. 373 

She had never had a miscarriage, and, so far as she knew, had never had 
uterine disease of any kind. She was a woman of magnificent physical 
development, weighed 230 pounds, and was full of courage. She had 
always menstruated regularly; but for several years had flowed for six 
or seven days at a period. On August 12th, exactly five weeks previous, 
she menstruated regularly, and the flow continued for six days. On 
August 29th, without warning, she suddenly had a severe pain resem- 
bling a labor pain, which continued for ten minutes, and was accom- 
panied by nausea and vomiting. On August 31st, while travelling on 
the cars, this pain recurred and lasted half an hour. While away from 
home she had two or three short, severe pains and a slight diarrhoea. 

Fig. 248. 




Primary intraperitoneal rupture ; fifth week. Tube completely ruptured, 
a. Ovum still slightly adherent to its original site. 

On September 9th, after her return home, she began to menstruate 
exactly on time, but the flow was checked by a sudden fright, her son 
being seized with convulsions in her presence. The same evening she 
had another short, acute attack of abdominal colic. The menstrual flow 
returned the next day, but ceased after a few hours. It again returned, 
but ceased two days before the final attack. 

When first seen by the writer it was evident from the profound col- 
lapse, indicated by the total absence of radial pulse, and the excessive 
pallor and death-like coldness of the body, that the patient was suffer- 
ing from internal hemorrhage; while the dyspnoea made it plain that 
the time for action was short, and that if something was not immedi- 
ately done it would be too late. Further physical examination revealed 
nothing more than local tenderness over the whole abdomen. Sudden 
pressure would elicit repeated expressions of pain. 

A careful and thorough vaginal examination was made, which was 
entirely negative. The fact that she was flowing at the time, of course 
directed my attention to the pelvic organs as the probable source of 
hemorrhage, and the information obtained from the patient's friends 
and from herself, regarding the previous attacks of pelvic pain, made 
the diagnosis of ruptured tubal pregnancy more than probable. Two 
objects were therefore kept in mind in making the examination. First, 
the determination of the presence of free blood in the abdominal cavity, 
and, second, the discovery of a mass to one or the other side of the 



374 



PATHOLOGY OF PREGNANCY. 



uterus. The examination failed, however, in both respects; repeated 
percussion over the abdomen absolutely failed to give any impulse or 
sense of fluctuation, either upon deep digital pressure into Douglas's 
pouch or at either side of the uterus, and no enlargement of the Fallo- 
pian tubes could be detected. The thickness of the abdominal walls in 
this patient greatly increased the difficulty of and embarrassed the ex- 
amination. 

The correctness of the diagnosis became evident even before the peri- 
toneum was incised. After the incision was made and the intestiues 
pushed back, the blood surged out over the surroundings. A careful 
estimate of the amount of blood in the abdomen would place it at not 
less than eighty ounces. The right Fallopian tube was found to be 
widely ruptured at its middle and the ovum embraced by the gaping 
edges of the wound (Fig. 247). The lumen of the tube was perfect ex- 
cepting at the seat of rupture. 

The fimbria? were partially drawn into the abdominal ostium. There 
was a great attenuation of the tubal wall at the location of the tear, 
which occurred at a point opposite to the seat of attachment of the ovum. 

Fig. 249. 




Unruptured ampullar pregnancy at the end of the second month (embryo about 2 cm. long. The 
thinnest part of the gestation sac has been removed after the operation. 

Primary Extraperitoneal Rupture— Hematoma of the Broad Ligament. 
An extra-uterine pregnancy, instead of developing in the direction of the 
free abdominal cavity, may grow downward and cleave the folds of the 
broad ligament without rupture of the tube proper, the adjoining portions 
of the broad ligament stretching gradually to accommodate the growing 
ovum. As a rule, rupture occurs between the seventh and twelfth week 
of pregnancy. 

Here we have, first, the usual signs of extra-uterine pregnancy, together 
with the constant presence of a mass contiguous to and connected with 
the uterus. Rupture is indicated by an increase in pain and faintness. 
The signs before this accident are often not sufficiently marked to denote 
the character of the pregnancy, and, as a rule, the patient believes her- 
self pregnant in the normal way. Whereas, in the early primary intra- 



ECTOPIC GESTATION. 375 

abdominal rupture faintness and syncope are the most striking symptoms, 
and the pain not so severe, in this variety severe pain is usual, while 
the collapse is not so extreme. The paiu in most cases is recurrent and 
paroxysmal, coming on without warning and usually soon passing away, 
to be followed by another series of paroxysms a few hours or a few days 
later, each attack probably indicating an extension of the rupture. As 
the blood effused is limited by the resistance of the adjoining structures, 
we do not witness those appalling symptoms common to the already men- 
tioned intraperitoneal ruptures. 

To make the picture plain regarding these cases, if a woman of child- 
bearing age suddenly complains of severe pelvic pains, accompanied by 
nausea and faintness; if, on investigation, she says that she has missed 
one, two, or three menstrual periods, or has flowed in a very irregu- 
lar manner, and thinks herself pregnant; if she has the usual vulvar 
and vaginal discolorations common to pregnancy and the changes in the 
breasts, with nausea, and if these attacks of pain and faintness recur, 
extra- uterine pregnancy must be strongly suspected. If, on examination, 
the uterus is found enlarged, but not to a sufficient degree to correspond 
to a pregnancy of that age, while immediately adjoining the uterus and 
continuous wath it a tense and vaguely fluctuating enlargement is discov- 
ered, then ectopic gestation, ruptured extraperitoneally., is a reasonable 
conclusion, and the case may be so regarded and treated. The signs 
mentioned may not all be present, and many cases are sufficiently ob- 
scure to bring doubt, but to the experienced surgeon there are usually 
landmarks enough to outline the course to pursue. 

Early cases of this kind undoubtedly occur which are not diagnosed, 
the ovum and secundines being gradually absorbed and the patient never 
being very ill; but when the accident takes place after the seventh week 
severe illness generally ensues. Even at ten and twelve weeks the rupture 
may have proceeded so evenly and slowly that the patient may not seek 
medical advice until constitutional symptoms indicative of sepsis appear. 

In the very great majority of cases the ovum dies at the time of the 
rupture, and no further growth occurs. The traumatism existing, how- 
ever, leads to the formation of protective exudate, which very materially 
increases the size of the whole mass. This increase in size gives rise to 
more pronounced pain, and sooner or later, in almost all cases, sepsis 
supervenes and the mass breaks down into a suppurative focus, while 
the patient develops fever, sweats, chills, and the usual constitutional 
evidences of retained septic material. 

In patients seen for the first time in this condition, the diagnosis is 
often difficult, and in some, where the history is not very typical, is even 
impossible, as the signs differ little from those of the common forms of 
septic pelvic invasion. Careful inquiry into the history is the best reli- 
ance for avoiding mistakes. 

Secondary Ruptures. This term applies only to the last-named variety, 
namely, the extraperitoneal variety, where the ovum, after forcing its way 
below the peritoneum in the folds of the broad ligament, ruptures into 
the general peritoneal cavity. These secondary ruptures may occur from 
different causes. After the primary rupture the ovum may survive, and 
its continued growth almost invariably results in communication with 
the general cavity. This variety of secondary rupture is sometimes 



376 PATHOLOGY OF PREGNANCY. 

sudden, and the effusion of blood into the general cavity may be so exten- 
sive as to give rise to the most serious symptoms with fatal results. The 
appearances are very similar to those of primary rupture of early date, 
and the treatment must be equally prompt. A secondary rupture may 
follow a primary rupture so closely that they can hardly be differentiated. 

In other cases, however, the ovum surviving, the secondary rupture 
may be slow and not extensive, the opening reinforced by quickly formed 
exudate and the symptoms more subdued. Such accidents may occur 
time and time again, and, if the ovum is not destroyed, there develops 
that class of so-called advanced, abdominal, extra-uterine pregnancy 
which will hereafter be described. 

When the ovum is destroyed by the primary rupture, secondary rup- 
tures may still occur. If the first rupture has so separated the ligamen- 
tous folds that only a thin peritoneal membrane is interposed between 
the mass and the general cavity, blood-pressure alone from recurrent 
hemorrhages may complete the rupture; or, the whole mass including its 
peritoneal covering becoming macerated and softened by sepsis, second- 
ary rupture may result from lack of consistency. 

The interstitial or tubo-uterine and infundibular or tubo-ovarian vari- 
eties of ectopic gestation are especially prone to early primary intraperi- 
toneal rupture. In the true tubal variety, if the placenta is implanted 
on the superior inuer surface of the tube, extraperitoneal rupture is more 
likely to occur; if, on the contrary, it is implanted on the lower inner 
surface, the upper part of the tube thins out, and early rupture into the 
general peritoneal cavity is most probable. Almost all the extraperi- 
toneal ruptured cases belong to the true tubal variety. 

B. After the Fourth Month. 

Unruptured Tubal Pregnancy. When the ovum survives all the dangers 
which threaten its existence, new signs become evident after the fourth 
month which demand separate consideration in their relation to diagnosis. 
Few ectopic gestations survive the fourth month, and very few, indeed, of 
these have not been subject to more or less rupture, either intra- or extra- 
peritoneal. Most of the reports of examinations of extra-uterine cases are 
not sufficiently minute and explicit to base a positive opinion upon; but, 
nevertheless, there can be no doubt that women have passed through 
extra-uterine pregnancy to term, carrying the child within the enlarged 
dilated tube, without appreciable rupture in any direction. Many of the 
reported cases of this variety have, however, been shown to have previ- 
ously ruptured slowly below, between the folds of the broad ligament. 

Abdominal Pregnancies Without Rupture. The space at command will 
not admit of reviewing the discussion whether such a condition can 
exist. Suffice it to say that advocates of that theory believe that an 
impregnated ovum can find its way into the general cavity or that an 
ovule can there become impregnated and implanted, and grow even to 
full term without rupture. Their opponents stoutly maintain that all 
so-called abdominal pregnancies were originally tubal, that rupture took 
place into the general abdominal cavity, but that sufficient attachment to 
the tubal mucous membrane remained to nourish the ovum, and that 
eventually, although the placenta became universally attached to sur- 



PLATE XXX. 




Left Tubal Pregnancy operated on five months after signs of life had 
disappeared. The superior surface of the left tube is still visible on the 
surface of the sac. The left ovary was visible only as a bluish flattened 
patch apparently forming a part of the sac wall. The sac developed between 
the folds of the mesosalpinx and mesosigmoid. The patient was suffering 
from uterine hemorrhage, but had never been seriously ill. There had 
never been signs of rupture, and the whole sac was dissected intact into the 
eornua of the uterus. 



ECTOPIC GESTATION. 377 

rounding structures, all cases that were examined with sufficient care by 
competent authorities could always be traced to the tube as the original 
site of primary implantation. The consensus of opinion at this date 
inclines to the latter view. (See Plate XXX.) 

In almost all cases of advanced ectopic gestation we have the symp- 
toms and signs common to uterine and ectopic gestation, namely: 

Disturbance of menstruation; 

Changes in the breasts; 

Enlargement of the uterus; 

Xausea; 

Changes of the vulva; 

Thinning out and softening of the lower uterine segment; 

Mucous vaginal discharges; 
as well as the symptoms heretofore described as resulting from rupture 
of greater or less extent in the earlier months. 

As the gestation advances beyond the fourth month the other signs 
which become manifest demand special consideration. Of these the 
principal are: (1) changes in the breasts characteristic of advanced preg- 
nancy; (2) movements of the foetus; and (3) abdominal enlargement; 
while careful examination often reveals (4) ballottement; and (5) pla- 
cental souffle. 

1. Changes in the Breasts. These are practically similar to the changes 
which occur in uterine pregnancy, but are generally not so well marked; 
the areola is not so well defined, the breast not so full, nor the secretion 
so abundant. 

2. Movements of the Foetus. The perceptibility of these movements 
differs according to the variety of the case. When dealing with a case 
of so-called abdominal pregnancy, the result of secondary rupture into 
the free peritoneal cavity, if the patient is reasonably thin, the move- 
ments are often extremely plain to the examiner, even when hardly 
noticeable to the patient. When near term and the child is reasonably 
vigorous, the movements may be felt and seen so plainly immediately 
beneath the abdominal wall as to form a valuable diagnostic sign. In 
the subperitoneal forms the movements are not so plain, but may be very 
painful to the patient, although they closely resemble those of the foetus 
in utero. Generally speaking, if the pregnancy advances to the fifth 
month, the movements of the foetus are thereafter more plainly discerni- 
ble than are those of a uterine pregnancy of the same age. 

3. Abdominal Enlargement. Proper and painstaking observation of the 
abdominal enlargement of a woman supposed to be with child extra- 
uterum is a matter of the very greatest importance. While the ovum 
is small and the mass containing it is buried in the pelvis, the abdomen 
is, of course, not enlarged. When the enlargement becomes discernible, 
it differs according to the variety of the case. In general, it may be 
said that it differs materially from normal gestation in that it is not so 
symmetrical nor is it, at first, so centrally situated. If the patient is the 
victim of an interstitial pregnancy it may show very soon after the third 
month, usually slightly to one side. If the gestation is free tubal and 
subperitoneal the enlargement will usually show first on the side affected, 
generally resonant from superimposed intestines and more or less irregu- 
lar and nodular; while if abdominal it will be still more irregular and 



378 PATHOLOGY OF PREGSASCY. 

nodular, the mass plainly recognizable, and unless adhesions have formed 
to the intestine it will be dull on percussion. The mass is often wider 
from side to side and differs essentially from the smooth ovoid of the 
normally pregnant uterus. 

Bimanual examination, rectal and vaginal, of a six to seven months' 
ectopic gestation will for the experienced examiner throw much light 
upon the nature of the case. The uterus at this stage can usually be 
outlined, and a well-marked groove between the uterus and sac can often 
be made out. Great care must be taken, however, in reaching a definite 
conclusion : A pregnant retroflexed uterus in some cases is most decep- 
tive, while an advanced unruptured true tubal or interstitial pregnancy 
may be so intimately blended with the uterus as to make the outlining 
of that organ well-nigh impossible. In true tubal unruptured pregnancy 
and in the ruptured subperitoneal variety a sign of importance is the ob- 
literation of the vaginal fornix on the affected side. (See Plate XXXI.) 

In cases where there have been repeated ruptures with hemorrhages 
surrounded by exudate, the diagnosis is sometimes very difficult, the 
abdomen and pelvis being filled with irregular masses varying in size 
from small nodules to lumps the size of a fist, and the whole matted 
together by adhesions. The uterus is adherent to these masses, fused 
among them, and often indistinguishable from them. 

The foetus itself may be palpated sometimes with the very greatest 
ease, and the extreme thinness of the tissues between the overlying hand 
and the foetus is often quite a characteristic sign. Palpation of both foetus 
and uterus is frequently rendered difficult, however, by the implantation 
of the placenta upon the anterior wall of the sac. 

If the sac is interstitial it may still retain its central location, but its 
length will be out of proportion to its breadth. If tubal, the uterus will 
usually be pushed to one side, and almost always be crowded up behind 
the pubes, as in the majority of cases the sac settles down in Douglas' 
pouch. If the pregnancy develops very low down, and if adhesions do 
not form, the uterus may be so crowded up that the cervix can hardly be 
reached. The size of the organ does not correspond to the age of the 
suspected pregnancy, varying, when the case is at term, from four to six 
inches in depth. In some women examined at this time, the nature of the 
case is most apparent, the important item of diagnosis being the outlining 
of the uterus proper and the determination of its location as independent 
of the sac. 

4. Ballottement may be elicited either anteriorly or posteriorly to the 
uterus. 

5. Placental Souffle. This sign, common to normal as well as to extra- 
uterine pregnancy, is of significance only in a small proportion of cases. 
It begins to be heard about the end of the third month, but is often very 
faint. In secondary abdominal ruptures, when the placenta spreads out 
anteriorly just beneath the abdominal wall, it may prove a valuable sign, 
as it is then extremely loud, is sometimes spread over almost the entire 
abdomen, and by its intensity, suggests the character of the case. 

General Conclusions Concerning Signs and Diagnosis. From a perusal of 
the foregoing remarks on the signs of ectopic gestation it becomes evi- 
dent that the existing variations are misleading by reason of their great 



PLATE XXXI. 




Secondary Abdominal Pregnancy at Eight Months, Primarily Tubal. The 
primary attachment of the placenta is plainly discernible at the original tubal 
site. After rupture the placenta grew and became attached to a large surface 
on the anterior abdominal wall. The child was delivered through a retro- 
uterine vaginal incision. 



ECTOPIC GESTATION. 379 

diversity, and yet the diagnosis, after a time has elapsed, is not usually 
attended with as much difficulty as might be inferred. 

Diagnosis is well-nigh impossible in patients who come under observa- 
tion early in pregnancy and before any degree of rupture has occurred. 
There are then present evidences of pregnancy and a mass adjacent to 
and, moreover, connected with the uterus. If such a patient has been 
carefully examined within four or five months, or just before the begin- 
ning of the ectopic gestation, and no mass found, the recent appearance 
of the latter becomes extremely significant. If no such opportunity has 
been offered, however, there is often little, if anything, to differentiate 
between the gestation sac and a possible cystic enlarged ovary, a dermoid 
cyst, or any condition characterized by such an enlargement and not 
inconsistent with pregnancy. 

One can seldom be certain in this class of cases. Beside the signs of 
pregnancy and the presence of the enlargement alluded to, it can only be 
mentioned as an aid in diagnosis that there is usually more pain, which 
the patient describes as griping or colicky, coming on sharply and 
leaving suddenly, to be soon repeated, usually lasting from a few hours 
to a day or two, and followed, it may be, by a respite for a few days, 
when another series of pains occurs. The lump felt near the uterus may 
also be said to be rather soft and possibly slightly fluctuating ; it is 
generally unattached and movable and throbbing because of enlarged 
vessels. 

If hemorrhage occurs from the uterus, however, very great assistance 
is derived from a microscopical examination of the discharge, as by this 
is often revealed the presence of decidual cells and the absence of chori- 
onic villi. 

AY hen primary rupture into the abdomen occurs very early, say from 
the fourth to the eighth week, the hemorrhage in the abdominal cavity 
is usually large, and these cases present a most striking and almost un- 
mistakable picture. 

Subperitoneal ruptures take place from the seventh to the twelfth 
week of pregnancy. Before rupture the paroxysms of pain are more 
frequent and the pains more severe, and the shock resulting from the 
rupture is not so great. Examination at this time reveals a large semi- 
fluctuating mass filling one side of the pelvis, more or less obliterating 
the vaginal sulcus on that side, with a broad base and so intimately 
blended with the uterus as to make the outlining of the latter difficult. 

In secondary ruptures in the peritoneal cavity we find the symptoms 
just described under subperitoneal rupture, followed by those which 
belong to primary ruptures. 

The symptoms of advanced ectopic gestation are the symptoms of 
advanced pregnancy with infinitely more general abdominal disturbance 
than is usually found in uterine pregnancy of the same age. These dis- 
turbances are due not only to the conditions already described, but to 
innumerable, accidental, coexisting complications. 

In the subperitoneal variety displacement of contiguous organs must 
necessarily occur. The bladder, uterus, rectum, ureters, and kidneys are 
always more or less displaced or compressed, with resultant disturbance of 
function. Hence we frequently observe dysuria, indigestion, and consti- 
pation, even to the point of obstruction, or it may be hydronephrosis or 



380 PATHOLOGY OF PREGNANCY. 

nephritis, with or without eclampsia, and excessive oedema from compres- 
sion of the vessels. 

Peritonitis, which is a constant complication, is especially severe in the 
abdominal variety. Whereas, fatal general peritonitis is sometimes set 
up by the rupture of an early tubal pregnancy, in advanced pregnancy 
it usually assumes a more chronic type, producing great alteration in the 
sac-wall and universal adhesions, so much so that the relations of the 
various structures are recognized with difficulty. 

Hemorrhage is also very common, not the excessive hemorrhage into 
the peritoneal cavity which occurs in early pregnancy, but repeated, 
small hemorrhages circumscribed by surrounding adhesions. 

Pain is the dominant symptom in the vast majority of cases of advanced 
ectopic gestation with or without rupture. A few cases have, however, 
been observed in which a child has been carried to term extra-uterum 
without excessive pain. These were probably cases of unruptured true 
tubal pregnancy, and are extremely rare. Pain is the natural result of 
the visceral displacement, of the repeated hemorrhages, of the pressure 
upon nerves, and of the peritonitis. The pain which many women suffer 
in the later months of ectopic gestation is agonizing. 

False or Spurious Labor. Whenthe foetus has reached term, spurious 
or false labor supervenes. It may, however, occur earlier, at the seventh 
or eighth month. This peculiar phenomenon has attracted much atten- 
tion and given rise to many conjectures, but no very satisfactory explana- 
tion of its occurrence has been advanced. It differs materially in different 
patients, being sometimes abrupt, well marked, and consisting of defined 
contractile pains, gradually increasing in severity and lasting from a few 
hours to one or two days, and after reaching a certain degree of intensity 
gradually subsiding, it may be, never to return. In other patients it 
recurs a number of times several days apart, so that a woman may have 
had a number of so-called spurious labors. There is really but one true 
labor, and that follows or rather causes the death of the child. Pains 
recurring later are probably due to inflammatory changes in the gestation 
sac or to some complication. In some patients the movements of the 
foetus become gradually fainter, and the signs of active living pregnancy 
subside without the occurrence of false labor. 

Often during such labor the movements of the child become excessively 
active; when the climax of pain is reached all movements suddenly cease 
and the pains gradually subside. 

Accompanying these labor pains there is usually hemorrhage from the 
uterus, sometimes very slight, at other times very profuse, and if decidual 
membrane remains it is generally expelled. Are these pains caused 
by contractions in the uterus or in the gestation-sac? The changes 
that take place in the uterus, the expulsion of membrane in some cases, 
the almost constant occurrence of hemorrhage, indicate that in all cases 
the uterus contracts, but it seems almost impossible for notable contrac- 
tion to occur in the wall of a gestation-sac, often hardly thicker than 
parchment, and which possesses almost no muscular tissue. Probably 
contractions in the sac proper occur only in the subperitoneal, true tubal 
and interstitial varieties, where the sac wall still contains a good deal of 
muscular tissue. 

Changes After Spurious Labor. Well-defined spurious labor always 



ECTOPIC GESTATION. 381 

results in death of the foetus; following this there is subsidence of the 
abdominal swelling, and involution of the uterus, accompanied by mod- 
erate lochia! discharge resembling that of uterine pregnancy, but not 
so profuse. The placental souffle gradually disappears, being seldom 
noticeable after two or three weeks. The breasts may discharge milk for 
a few days. Well-marked and immediate decrease in the size of the 
abdomen is not always constant, sometimes because of delay in absorp- 
tion of the liquor amnii or because of increase in the placental bulk 
caused by hemorrhage from vessels ruptured during the spurious labor 
or disintegrated by septic changes. 

Sometimes following spurious labor septic symptoms appear, hectic 
fever develops, and the whole gestation-sac breaks down into a sup- 
purative gangrenous mass. The pus burrows in various directions, 
almost always finding its way into some adjoining organ or through 
the abdominal wall, whence it is expelled, the disintegrated remains 
of the foetus following the same channel. Numerous cases of gradual 
expulsion of the different parts of foetuses by way of the bladder, rec- 
tum, vagina, or abdominal wall are recorded in the literature. Very 
few, if any, advanced cases are mentioned as opening into the general 
peritoneal cavity and proving fatal by rapid septic peritonitis, because 
when the gestation-sac reaches certain dimensions the pressure and in- 
flammatory changes obliterate the general cavity and all the neighbor- 
ing organs become intimately adherent to the outer surface of the sac so 
that there is no free cavity for the pus to break into. This process of 
maceration, suppuration, and expulsion, however, is usually fraught with 
infinite pain and imminent danger to the unfortunate victims, many of 
whom die exhausted by hectic fever. 

In a reasonable proportion of these cases the foetus and its investing 
membranes and placenta undergo peculiar and interesting changes with- 
out septic symptoms, these changes resulting in the abdominal inclusion 
of the modified foetus, now styled lithopedion. This term is supposed to 
apply only to calcified foetuses, but is generally used to signify a foetus 
retained for a long time without putrefaction and suppuration. 

The changes may result in mummification, or calcification, or adipocere 
formation of the ovum, or the sac, or both, the same specimen frequently 
showing the various formations in different locations. 

Mummification seems to result from absorption of all the fluid por- 
tions of the foetus, and it may be of the sac and placenta, the hard bones 
remaining more or less intact, and the soft parts having the appearance 
of dark-brown, shrunken parchment. 

Calcification means hardening of all the parts from impregnation 
with lime salts. 

Adipocere formation refers to that condition in which the soft 
parts of the foetus and even portions of the bone are converted into a 
soft soapy mass, supposed to be due to a combination of the fats and 
ammonia. 

A foetal sac which has undergone these changes may remain in situ for 
an indefinite number of years. It is reported that many of them have 
been carried without harm for thirty, forty, and even fifty years, being 
then demonstrated post mortem. At any time, however, even after manv 
years, without apparent cause, infection of the sac may occur, attended 



382 PATHOLOGY OF PREGNANCY. 

with all the dangers described as resulting from primary septic infection, 
such as happens immediately after spurious labor. 

Treatment. 

1. Prior to the Fourth Month. 

General Considerations. Surgery offers the only treatment of value in 
ectopic gestation prior to the fourth month. In exceptional cases opera- 
tion is not advisable : 

When the patient is moribund, operation is useless. 

IVhen the patient is recovering, watchful expectancy may be all that is 
necessary. A blighted ovum can unquestionably be absorbed. The 
patient may not come under observation until recovery is well under 
way. If a mass, the character of which is undoubted, is painless on 
palpation, is known to be decreasing in size, and is becoming firmer in 
consistency, and if the patient presents no symptoms, under such circum- 
stances operation would be meddlesome interference. 

When the diagnosis is obscure. The ovum may be expelled through 
a patent ostium abdominale into the general peritoneal cavity, and be 
there absorbed, or it may perish and be absorbed in situ, or intra- or sub- 
peritoneal rupture may take place and the symptoms not be sufficiently 
marked or severe to establish a diagnosis or to demand exploratory 
incision. 

Morphine injections into the gestation-sac or the passing of a strong 
electric current through it, with or without puncture, are measures which 
were much in vogue in former years, the rationale of such measures 
being the destruction of the life of the foetus, trusting to nature to absorb 
the products of conception. Experience has proved beyond doubt the 
inferiority of these methods of treatment. It is often impossible to deter- 
mine whether the foetus is alive or dead, and its death, in the majority of 
instances, is not followed by absorption with cure of the patient. The 
employment of these measures does not make the diagnosis clear when 
there is doubt, and, beyond all, the manipulation and interference inci- 
dent to their thorough application have proved at least as dangerous as 
operation. 

In no department of surgery have the results been more brilliant, 
more perfect, and more life-saving than in the modern surgery of early 
ectopic gestation. 

(a) Before Rupture. 

Unless one of the above-noted exceptional conditions exists, unruptured 
ectopic pregnancy prior to the fourth month should always be removed. 
This is usually best accomplished by median abdominal section with 
removal of the affected tube and its contents. The operation is ex- 
tremely simple, as adhesions are not usually present. A ligature is placed 
on either side of the mass, and the latter excised completely, bleeding 
points being caught and, if necessary, ligated. The cut surfaces are 
brought together by means of catgut sutures, thereby maintaining the 
function of the broad ligament in supporting the uterus in position, and 
another overhand continued suture, to cover traumatism and sutures with 



ECTOPIC GESTATION. 383 

peritoneum, thereby preventing adhesions, adds to the safety of the 
patient. Although we usually "employ catgut, the objections to silk are 
not of importance, for no septic focus is encountered, and if the opera- 
tion be properly performed, without the introduction of sepsis, the con- 
valescence will be rapid and without complications. 

When the pregnancy is of the interstitial variety an incision is made 
through the muscular layers down to the sac, which is then shelled out 
carefully, the bleeding being checked by one or two layers of buried 
sutures/ care being taken to cover the seat of operation with peritoneum 
by fine superficial sutures. In these cases it is particularly important 
not to close the abdominal cavity until all oozing has ceased. 

(6) After Eupture. 

1. Primary Intraperitoneal Rupture. In speaking of the symptomatol- 
ogy of this phase of ectopic gestation the statement was made that " The 
diagnosis of intraperitoneal rupture is the diagnosis of intra-abdominal 
hemorrhage, and the physical signs are identical." It may now be 
added that the treatment is that of intra-abdominal hemorrhage. The 
responsibility in some of these cases is immense; but the operator must 
not hesitate. Such patients frequently die in a few hours. The abdo- 
men must be opened and the bleeding point ligated. The symptoms are 
usually very acute and the hemorrhage most abundant. After the diag- 
nosis is established, the operation should be performed even if the patient 
has rallied, for the next hour may witness a new and, this time, fatal 
hemorrhage. Such patients are never safe, for they bleed repeatedly, and 
there is a gratifying uniformity of success following all these operations 
when the patient is not moribund. 

Acute Early Primary Ruptures with Free Abdominal Hemorrhage Should 
Always be Operated by the Abdominal Route. A woman suddenly faints, 
immediately receives competent medical assistance, but notwithstanding 
all treatment, in an hour or two is in profound collapse with the clinical 
signs of early primary rupture of ectopic gestation. This is a typical 
fulminant case, and the patient is bleeding to death. Abdominal section 
should forthwith be made and direct ligation applied. Fill the bowel 
with normal salt solution; place the patient in the Trendelenburg position, 
on the bed, if need be; thoroughly cleanse the field of operation; open 
quickly; dip the hand at once through the blood down to the point of 
rupture; place a clamp on each side of the rent; wipe away sufficient 
blood to enable ligatures to be passed; sweep the open hand a few times 
around the abdomen and remove the large clots and possibly the product 
of conception; exsect the tube; make sure of the hsemostasis and imme- 
diately close. The hemorrhage from the bleeding point can often be 
controlled in four or five minutes, and the operation completed in fifteen. 
During all this time, if necessary, continuous infusion of physiological 
saline solution into the cellular tissue is being made by an assistant. 

If during the operation septic material is encountered in the abdominal 
cavity, be it exudate around the affected tube or disease of the other tube, 
or doubtful conditions in the region of the appendix, or if the operator 
is not reasonably certain of the aseptic character of his manipulations, 
then, if the patient's condition permit, the abdominal cavity should be 



384 PATHOLOGY OF PREGNANCY. 

thoroughly cleansed, after which drainage would better be employed 
through the lower end of the wound or through the vagina. If, how- 
ever, the patient's strength will not allow such prolongation of the opera- 
tion, time may be saved by the introduction of a large Mikulicz drain. 

In arriving at a proper conclusion whether or not in a case of this 
variety the patient will still be able to bear operation, a symptom of 
considerable importance is the presence of great restlessness, as it fre- 
quently means impending death, and, therefore, might directly contra- 
indicate interference. Xo matter how profound the shock, a patient is 
very seldom beyond hope of safety by rapid operation if she does not 
exhibit this restlessness. 

Discrimination should be employed, if possible, in differentiating 
between recurrent temporary swoons and profound progressive collapse, 
and it should be remembered that the shorter the time between the begin- 
ning of the attack and profound collapse the more urgent the need of 
immediate operation. 

Blood is left free in the abdominal cavity when the conditions of asep- 
sis are supposedly maintained, because the shorter the operation the better 
the prospective recovery; the less the manipulations, the less the absorp- 
tive powers of the peritoneum are impaired, and because the absorption 
into the circulation of the serum left in the cavity begins at once and 
stimulates the patient pending the general revival of vital forces. 

The Trendelenburg position is advised because the presence of large 
quantities of blood in the pelvis frequently interferes materially with 
the proper application of ligatures; because inversion of the patient 
causes gravitation of much of this blood toward the diaphragmatic region, 
where it is more easily absorbed, and because this position lessens the 
syncope. 

In the primary intraperitoneal rupture of interstitial pregnancy the 
treatment is exactly the same as that just described, for the symptoms 
are, if possible, more acute, except that it is not always necessary to 
exsect the tube, as the cavity which is left after complete removal of the 
ovum is closed by successive layers of sutures. If the gestation has 
materially advanced before rupture occurs, the traumatism inflicted upon 
the uterus may be so serious as to necessitate hysterectomy. 

2. Subperitoneal Ruptures. Subject to the exceptions noted under the head 
of general considerations, removal of the offend iug gestation-sac is the 
proper treatment for the cure of patients affected with subperitoneal rup- 
ture. As the hemorrhage in these cases, however, is restricted by the 
surrounding structures, the symptoms are less acute and alarming, and 
the shock not so great, although the pain is often much more severe. 

Although there is no doubt that many of these cases would recover by 
the unaided efforts of nature without operation, the latter is much to be 
preferred when the patient is seen soon after the rupture, because it elim- 
inates many possible dangers, usually saves the patient much pain, and 
in the great majority of instances, results in recovery with complete and 
perfect physiological functions. When the patient does not come under 
observation until a considerable time has elapsed since the rupture, either 
she is convalescent or is suffering from complications, the treatment of 
which will presently be described. 

Acute non-septic subperitoneal rupture should always be treated by 



ECTOPIC GESTATION. 385 

median abdominal section. Especial care should be taken in opening the 
abdominal cavity when, as frequently happens, the rupture does not occur 
until the tenth to the fourteenth week, for adhesions may be present and 
the contents of the sac be septic. The Trendelenburg position materially 
facilitates the operation. After the abdomen is opened the first step, and 
one of great importance, is carefully to wall off the affected area with 
pads of aseptic gauze so as thoroughly to protect the healthy portion of 
the cavity and its contents. If fluctuation is evident in a portion of the 
mass, a very small incision is made to open this part first, or a trocar may 
be introduced, and the liquid contents caused to flow out slowly, being 
caught on large gauze sponges. The whole mass is then shelled out of 
its bed and the vessels ligated. In some easily accessible cases the ves- 
sels may be ligated first. Occasionally the hemorrhage is very free, 
and a Mikulicz pelvic tamponade becomes advisable. 

3. Secondary Ruptures. The treatment of secondary ruptures is similar 
to that of the primary intraperitoneal form. The most important item 
to be kept in mind is the liability of the contents of the sac to be septic; 
therefore, the patient should not be placed in the Trendelenburg position 
until the abdomen is opened, the parts, if possible, well isolated, and the 
peritoneal cavity cleansed to the extent that the condition of the patient 
will allow. 

Septic Cases and the Vaginal Incision. When a patient has 
passed safely through the first stage of rupture without operation, she 
may, and very frequently does, suffer from various complications, all of 
which are the results of sepsis. The woman with primary or secondary 
intraperitoneal rupture may die in a few days from general diffuse peri- 
tonitis. As soon as such a condition is recognized an abdominal in- 
cision should be made, the cavity carefully mopped out or irrigated with 
warm normal salt solution, if it seems impossible to cleanse it properly 
with gauze, after which a large drain may be left protruding through the 
lower angle of the abdominal wound, or through an opening made into 
the posterior vaginal cul-de-sac, or both. These extremely dangerous 
cases are, fortunately, rare. 

Generally the sepsis is local, involving at first only the gestation-sac 
and the affected tube and the blood-clots resulting from the hemorrhage 
at the time of rupture. Exudate protects the general peritoneal cavity. 
If suppuration follows, adjoining organs may become involved, and pelvic 
abscess, with all its possible destructive lesions, result. With a milder 
form of sepsis suppuration may not occur, but fib ri no-plastic exudate may 
eventually bind together all the affected parts and the adjoining organs 
in a conglomerate mass, giving rise to innumerable functional disturb- 
ances. 

In all these septic cases, if the mass is situated well down in the pelvis, 
vaginal incision with drainage is frequently the most desirable operation 
and is followed by the happiest results. The danger of hemorrhage 
usually disappears when septic conditions become manifest, because the 
vessels are occluded or much lessened in calibre. 

A wide incision is made through the posterior vaginal fornix, the mass 
thoroughly penetrated and broken up, and most of the debris removed. 
Abscess cavities are opened and drained, and adhesions thoroughly sepa- 
rated. Drainage, preferably with gauze, completes the operation. 

25 



386 PATHOLOGY OF PREGNANCY. 

If such an operation is skilfully performed it is safer and shorter than 
by way of the abdomen, avoids the abdominal wound with its scar and 
tendency to hernia, and seldom fails to cure the patient. A suppurating 
hematocele or a phlegmon of the broad ligament resulting from a very 
early rupture may consist simply of a single cavity. Drainage may be 
established through a small opening posterior to the uterus, and, although 
the procedure is so slight as scarcely to deserve the title of operation, the 
result may be ideal. 

The precautions essential to success in these vaginal incisions may be 
mentioned briefly as follows : 

1. Make sure that the incision is sufficiently large to permit thorough 
drainage. 

2. Make certain that no septic focus remains unexplored. A proper 
knowledge of the anatomy of the parts involved and reasonable tactile 
sense will enable the operator to avoid injury to important structures. 
In most instances it is less dangerous to open the free cavity and dis- 
engage ail the adhesions possible, than to leave inflammatory masses 
untouched. Pay especial attention to the condition of the ovary on the 
supposed unaffected side. 

3. Remove all blood and cleanse accessible soiled areas, but do not 
irrigate. 

4. Do not use tubular drains, but drain the various infected regions 
with long narrow strips of gauze, drawn out like rope the size of a lead- 
pencil, bunching them together, and sufficient in number at the lower 
end to form a large drain, which will keep the vaginal opening stretched 
wide, and produce pressure on the vaginal and cellular vessels behind the 
cervix. The many bunched-up, small, rope-like strips of gauze are much 
less painful to remove than the larger gauze drains ordinarily employed. 

5. Interfere with the patient as little as possible after the operation. 
If symptoms do not demand a change, allow the first drain or packing 
to remain in place for six or eight days; then remove it carefully and 
replace it by four or five small pieces, making a drain the size of a large 
forefinger, which should be allowed to remain in place for four or five 
days. Remove and replace once more, and in from fifteen to eighteen 
days remove the last drain and give vaginal douches. There will be a 
discharge for some time, but in three weeks fourteen out of fifteen of 
these patients will be practically cured. 

Beware of treating a recent intraperitoneal or subperitoneal rupture 
by vaginal incision and drainage before sufficient time has elapsed to 
make it reasonably certain that the vessels are occluded, for in some 
such cases you will witness the most furious hemorrhage from a remote 
point which cannot be reached through a vaginal incision. In case of 
doubt it is best to operate through a suprapubic incision. 

2. Aftee the Fourth Month. 

General Considerations. "When an ectopic gestation has advanced well 
into and beyond the fifth month there are various considerations of 
importance bearing directly upon the safety of the mother which demand 
recognition and call for the greatest exercise of judgment on the part of 
the surgeon. The development of the sac, the increase in the size of the 



ECTOPIC GESTATION. 387 

bloodvessels, the development of the placenta, and the probable presence 
of adhesions, all combine to increase the danger of interference very 
materially. As the gestation advances the whole mass does not present 
itself as a small lump around or on either side of which a ligature can 
be drawn and easy resection performed, but as a complicated condition 
presenting the most complex variations. 

In cases at or near term the life of the child is a consideration of great 
importance. Although voluminous arguments have been advanced advo- 
cating interference while the child is living, no definite rule can be laid 
down on this subject, and the peculiarity of each individual case must 
be the guide to the course to pursue. It is justly held by most humane 
surgeons that the life of the child should be held subordinate to that of 
the mother, and that, if extra risks are to be encountered by the latter 
in order to save the infant, it must be clearly understood that the respon- 
sibility must not rest upon the physician managing the case. 

When an advanced case comes under observation for the first time, say 
at the sixth month of gestation, shall the surgeon wait until the eighth 
month, and operate with the intention of saving the life of mother and 
child, or shall he operate at once, or shall he wait, as advised by some 
authorities, until spurious labor has occurred, that there may be less risk 
in the operation? These questions are most perplexing, but many 
patients present certain peculiarities or conditions that may aid us in 
reaching a conclusion. 

The condition here existing is materially different from that arising 
where a Cesarean operation is indicated, for in advanced ectopic gesta- 
tion the danger to the mother is infinitely greater while the life of the 
child is of minimum value, as has been sufficiently proved by the 
researches of Harris, of Philadelphia. 

A woman may be so reduced by repeated attacks of circumscribed 
peritonitis, recurrent moderate hemorrhages, and excessive pain that she 
can neither endure an operation nor continue in her present condition. 
In such a case, and there are such, the proper treatment is to resort to 
the old method; pick out some prominent foetal part, either abdominally 
or vaginally; insert a hypodermic needle deeply into the part, with aseptic 
precautions, and inject sufficient morphia, say half a grain, to kill the 
child, but not enough to harm the mother. If the child dies, placental 
souffle will disappear, the pain will subside, some considerable part of 
the liquor amnii will be absorbed, the dyspnoea will become less, and no 
more hemorrhages will occur, and in three or four weeks an operation can 
easily be performed. 

With a woman of strength and good health, with a child presenting 
favorably, and with a placenta that can apparently be easily avoided, the 
writer would advise endeavoring to save the child. At best, the dangers 
are always great, and, unless all symptoms are most favorable, the infant 
life should be ignored. 

Surgical interference in one way or another becomes necessary in 
almost all cases of advanced ectopic gestation, such interference being 
generally much safer than nature's efforts at relief. Patients with 
advanced ectopic gestation do not recover with ease without surgical aid, 
nor after careful analytical examination is the diagnosis usually obscure. 

As the foetal sac increases in dimensions the liability to sudden rup- 



388 PATHOLOGY OF PREGNANCY. 

ture, so characteristic in the earlier months, seldom occurs. The abdo- 
men is more completely filled and the adhesions more complete, causing 
more pressure and leaving less and less free space for large hemorrhages. 

Although the general diagnosis of ectopic gestation can usually be 
made with comparative ease, the difficulty of differentiating the variety 
becomes more difficult because of the occurrence of frequent small hem- 
orrhages and the presence of irregularly situated masses of exudate, the 
result of localized peritonitis. 

The object of all operations on ectopic gestation is the removal of the 
whole gestation sac, and this usually means removal of the affected tube 
in early cases. In advanced cases this is often impossible, but as the 
foetus is the most offending part of the gestation it is always removed, 
and, as absorption of the placenta and sac is a slow and more or less 
dangerous process, they should also be removed when possible. 

Hemorrhage is the greatest danger in these operations, and, therefore, 
avoidance of the placental site when practicable is of the utmost impor- 
tance. This danger is almost entirely eliminated soon after the death of 
the child, and the most favorable time to operate is after that occurrence, 
but before definite signs of sepsis become manifest. Wait two or three 
weeks, if possible, until the placental souffle has ceased, but be ready to 
operate at the least indication of sepsis. 

Because of this liability to hemorrhage, all these operations must be 
performed quickly and the parts brought well into view; therefore, in 
aseptic cases, which are those that bleed, when the child is supposed to 
be living, abdominal section is almost always the operation of choice. 

When the child is dead and the placental souffle extinguished, it may 
occasionally be found advisable to operate per vaginam if the child is 
very superficially felt in the posterior cul-de-sac, and there appears to be 
no bar to extraction by that route because of the size of the foetus. The 
cases in which this method is advisable are, however, extremely rare, the 
difficulty of reaching and properly detaching the placenta being greater 
by the vaginal route. 

The vaginal incision will usually prove available only for the cases in 
which sepsis is well developed and the gestation sac is filled with putrid 
material and a decomposed foetus, and presents in the vagina in such a 
manner as to form a clear indication. 

The abdominal incision need not be median. The surgical sense of 
the operator must indicate the incision by which the foetus can best be 
reached and the placenta avoided. 

As removal of the foetus is a matter of necessity, its location becomes 
a guide to the character of the operation. It must be remembered, how- 
ever, that the exact site of the child and its relation to the peritoneum 
are frequently not determinable until after the incision is made, and 
sometimes not even then, but nevertheless a proper understanding of the 
peculiarities of the different varieties of cases materially assists intelligent 
treatment. 

(a) When the Fcetus is in the Unruptured Tube. If the ges- 
tation is of the infundibular variety there is great doubt whether it can 
ever develop so as to be included in the category of advanced unruptured 
tubal pregnancy. The very great majority, if not all, the cases are, 
therefore, ampullar or interstitial. In the latter variety the uterus has 



ECTOPIC GESTATION. 389 

been dilated, its fundus cut through, and the child extracted. The proper 
and reasonable treatment, however, is simple abdominal section, made, 
if practicable, over the most prominent protuberance of the tumor, usually 
near the median line and low down. The external layer of the sac, or 
rather the tube, is often found adherent to the anterior wall of the abdo- 
men, and the sac may frequently be freely opened without entering or 
even perceiving the free abdominal cavity. Every care should be taken 
to endeavor to avoid the placental site by careful and frequent ausculta- 
tion before the operation, and by carefully deviating the inner incision, 
if possible. 

The sac being opened, the child is at once extracted, and passed to an 
assistant, another assistant devoting his attention during this time to the 
compression of the broad ligament at each side of the sac. The upper 
border of this ligament on the affected side, if it can be isolated, may be 
ligated before the sac is opened. 

The important step is the management of the placenta. If the child 
was living when the operation was begun, and the placenta was not mate- 
rially injured during the operation, great surgical sagacity is needed to 
determine whether its extraction should be attempted. If it is con- 
veniently situated and the surgeon has faith in his ability to control the 
blood-supply, it may be rapidly shelled out and a firm packing of gauze 
relied on to control the hemorrhage. If deeply attached and the large 
lower vessels are inaccessible because of adhesions, the placenta may be 
left in place and a firm gauze tampon relied on to check the flow of blood. 
If the child has been dead for a few days the placenta may be removed 
at once with only slight risk. No attempt should, as a rule, be made to 
remove the sac in this variety of cases. If the sac or uterus or both 
has been extensively lacerated, and hemorrhage seems uncontrollable, it 
is better to remove the uterus and sac together. 

The edges of the incision in the sac should be sewed to the edges of 
the abdominal wound and the cavity packed with gauze, whether the 
placenta is removed or left in place. In the latter case, after a few days, 
the placenta can usually be removed with much less risk. If at any 
time, however, sepsis occurs, immediate removal of the placenta becomes 
imperative. 

(6) When the Fcetus is in the Abdominal Cavity. These are 
usually, if not always, cases in which the gestation was originally tubal, 
and in which primary or secondary rupture into the free cavity took 
place so gradually that no very general hemorrhage occurred, and the 
foetus simply lies in a sac formed of the chorion and amnion, which in 
time becomes attached indiscriminately to most of the adjoining struc- 
tures. Kemoval of the sac with the placenta in this variety is very 
difficult, tedious, and dangerous. After the abdomen is opened a place 
is found where the vessels are least numerous, the sac opened at this 
point and the child extracted. Unless the child has been dead some 
days, no attempt should be made to remove the placenta, which is usu- 
ally deeply embedded in the pelvis at its original site. The sac is care- 
fully packed with gauze, which is left protruding from the lower anole 
of the wound. The sac w 7 ound is attached, if possible, to the abdominal 
wound, and the abdominal wall closed down to the gauze at the lower 
angle. After a few clays some of the stitches can be removed, and the 



390 PATHOLOGY OF PREGXAXCY. 

placenta extracted, a new packing being carefully placed in the sac. If 
practicable, the ovarian artery should always be ligated on both sides 
of the mass. 

In the case represented by Fig. 249 the author was enabled to shell 
out the sac in its entirety, the convalescence being thereby made as 
simple as the simplest of abdominal sections. 

The abdomen should be bandaged rather snugly, excepting exactly 
opposite the drainage, lest removal of pressure provoke hemorrhage. In 
some cases the placenta may have spread out rather thinly over a great 
part of the anterior surface of the thin sac, and may be encountered 
above at almost all points. 

If the child is small and packed down in the pelvis, and appears 
within easy reach by the vagina, it may in rare instances be extracted 
with more ease through a vaginal incision. 

(c) When the Fcetus is Subperitoneal. The treatment differs 
but little from that of the varieties just described; but mention should 
be made here of two points : As the peritoneum is pushed upward and 
toward the unaffected side, the incision must be very low and often some- 
what oblique, so as to reach the sac without entering the general cavity. 
The mass cannot be removed, because it is undefined, the membranes and 
peritoneum having become blended and fused together so as usually to 
obliterate even the semblance of a sac. 

The operations just described are frequently extremely hazardous, and 
it is well to bear in mind that the primary object of interference is the 
removal of the fcetus. At this juncture the exact conditions of the 
patient must carefully but quickly be determined. If the operation is 
then proceeded with, it may be necessary at a moment's notice to leave 
the removal of the sac unfinished and trust to firm packing with gauze 
to control the hemorrhage. Some operators have simply tied off the 
umbilical cord as near the placenta as practicable and have closed both 
sac and abdominal wall without drainage, and with reasonable success, 
although the advent of sepsis renders early reopening and placental 
extraction necessary in the majority of cases. 

When in an advanced ectopic gestation the foetus is dead and symp- 
toms of sepsis make it manifest that suppuration has occurred, the sac 
should be opened, all its contents removed, and drainage established. 
Whether this should be done through an abdominal or a vaginal incision 
depends upon the peculiarities of the individual case. Ordinary surgical 
sense must enable the operator to determine the easier route, for with due 
precautions regarding the rules of asepsis the easier method is generally 
the safer. The proper combination of the two may be advisable; for 
example, with a great deal of pus presenting plainly in the direction of 
the vagina, and a large fcetus, it may be better to make an incision below 
and evacuate the most of the liquid contents, or have a competent assist- 
ant do this, and immediately open above and extract the child. 

If pus has already found its way into the bladder, and the fcetus is 
much macerated, and already partially in the viscus, the latter may be 
opened from the vagina and the child extracted piecemeal. If the same 
accident has occurred by way of the rectum, the anus may be dilated and 
delivery be effected, or rather assisted, from that direction. Or vaginal or 
abdominal incision may be made if these other methods seem impracti- 



ECTOPIC GESTATION. 391 

cable or too dangerous. Common sense and surgical ability point out 
the direction attended with the least risk. 

When a patient formerly the victim of ectopic gestation comes under 
our observation only after the foetus has become mummified or has under- 
gone adipocere or calcareous formation, if the symptoms demand inter- 
ference, the operative indications already presented as applying to a 
recently dead foetus will suffice. 

Eepeated Ectopic Gestation. 

A number of instances are recorded in which one tube having been 
removed for ectopic gestation, impregnation has occurred at a later date 
in the remaining tube, as has been determined by operation or autopsy. 
Several cases have also been reported in which undoubted proof has been 
furnished of two or even three gestations in the same tube. Uterine 
pregnancy in the presence of a retained foetus, the result of a previous 
extra-uterine pregnancy, has been frequently noted. This may interfere 
mechanically with delivery, and its removal may become necessary. 

Twin Ectopic Gestation. It is claimed that twin pregnancies may occur 
outside of, the same as within, the uterus, but recorded cases of the kind 
are rare, and very few of these are so perfectly described that their validity 
is indubitable. 

Concurrent Ectopic and Uterine Gestation. Concurrent ectopic and 
uterine pregnancy may progress equally even to full term, or either foetus 
may prematurely perish. The treatment of such cases when pregnancy 
is advanced presents the most formidable complication known to the 
obstetric surgeon. There is no recorded instance of the survival of a 
mother after removal on the same day of two living children at or near 
term, one being intra-uterine and the other extra-uterine. Although 
text-books do not prescribe the course to pursue, this experience fur- 
nishes an indication for treatment. 

Two courses may be followed : 1. As soon as the diagnosis has been 
established, the extra-uterine foetus may be sacrificed. It is rare that the 
advanced extra-uterine foetus cannot be safely reached with a fine-explor- 
ing-needle. Sufficient morphin, say one-third to one-half a grain, may 
in this way be injected into the body of the child, thus destroying its 
life without injuring the mother. Ten days or two weeks later, or at the 
slightest indication of sepsis, uterine contractions may be gently and care- 
fully brought on, and a reasonable chance thereby be given to both the 
uterine child (if it be viable) and the mother. The extra-uterine foetus 
can be dealt with later, according to the indications. Even if inter- 
ference becomes necessary very soon after delivery, this secondary oper- 
ation would be much more likely to be successful because of the probable 
elimination of abdominal hemorrhage, which is the predominant danger 
in all such cases. 

2. Labor may be carefully induced and the ectopic gestation ignored 
and treated independently at a later period. A case was reported from 
Chrobak's Clinic in February, 1896, in which abdominal section was 
performed on a woman who had been delivered of her uterine child five 
days before, and a living child extracted from the abdomen. It was 



392 



PATHOLOGY OF PREGNANCY. 



found necessary to remove the uterus with the gestation-sac. Mother 
and both children survived. 

The general advice may be given : Never operate on an advanced living 
ectopic gestation in the presence of an advanced living concurrent uterine 
pregnancy. 

Cornual Pregnancy. Arrest in the development or failure of coales- 
cence of the Mullerian ducts in foetal life may result in what is known 
as a bicornate uterus. When pregnancy occurs in one of the horns of 
such a uterus, the pregnancy may result in normal delivery, providing the 
horn is well developed. If, however, the horn is rudimentary and does 
not communicate freely and properly with the lower genital tract, we have 
a condition so closely resembling real ectopic gestation that it is usually 
described in the treatment of this subject. 

The symptoms, course, and treatment of this condition require no 
further consideration than the statement that it is to all intents and pur- 
poses an ectopic gestation, presenting the same signs and requiring sim- 
ilar treatment. 

Utero-abdominal or Traumatic Ectopic Gestation. A pregnant uterus 
may rupture, the foetus may escape and develop in the abdominal cavity, 
the placenta retaining sufficient attachment to nourish the child. Leo- 
pold has reported such a case operated upon at term. 

Fig. 250. 




Utero-abdominal or traumatic ectopic gestation. 



The following case came under the writer's observation in 1895 : The 
patient, in the desire to terminate an existing pregnancy, introduced a 
sharp instrument into the uterus when about seven weeks pregnant. 



ECTOPIC GESTATION. 393 

After two and a half mouths of intermittent suffering attended with 
subacute septic symptoms, an operation was performed which revealed 
the condition represented in Fig. 250. The foetal sac still intact, about 
four or four and a half months advanced, was found in the free abdom- 
inal cavity, where it had been developing since the injury which caused 
its expulsion from the uterus. The placenta was still adherent to its 
original site, but had become attached to the uterine rent and to the 
adjoining external uterine surface. 



CHAPTEE XVIII. 

DISEASES OF PKEGNANCY. 

The diseases of pregnancy include only those morbid processes which 
find their causes in the gravid state itself, and which would tend to dis- 
appear were the gestation brought to a close. All pre-existing disorders, 
as well as those of non-gravid origin, are considered under the head of 
Complications of Pregnancy. 

Toxaemia of Pregnancy. 

This is one of the most important of the diseases of pregnancy, owing 
to the fact that there is a growing tendency to look upon toxicity of the 
maternal blood as an underlying element in the production of almost 
every disease mentioned in this chapter. If, then, the most important 
diseases of pregnancy may be only symptoms of toxaemia, we should 
carefully look into the conditions which favor auto-intoxication. 

The metabolic processes of the body are continually producing a large 
quantity and variety of waste-material, which, after passing through 
complicated transformations, is eliminated through the intestines, skin, 
kidneys, lungs, and liver. The fact that these waste-products are 
exceedingly poisonous is proved by the appearance of grave symptoms 
when elimination from the body falls below a certain standard, and also 
by observing the results of the artificial inoculation of animals with 
excreted material. The study of the physiology of excretion shows us 
two ways in which the animal organism may be exposed to the dangers 
of auto-intoxication. First, that great transforming organ, the liver, 
may fail to perform its duty, so that the products of tissue-waste are 
not converted into a chemical structure appropriate to the functions of 
the eliminative organs, and there will accumulate within the body certain 
poisonous precursors of urea. Second, through disease or functional 
insufficiency the eliminative organs themselves may not protect the 
organism against the development of a dangerous toxaemia resulting 
from retention of waste-products in the blood. There are two reasons 
why the pregnant woman is peculiarly exposed to the dangers of auto- 
intoxication. First, her blood contains an increased amount of poison- 
ous material due to (a) stimulation of the metabolic processes to provide 
for the nourishment and protection of the foetus, and (b) the tissue-waste 
passing into her circulation from the foetus. Second, as the uterus 
enlarges there must be a constantly increasing intra-abdominal pressure 
with a growing liability to mechanical interference with the action of 
the liver, bowels, and kidneys or, as some writers suggest, the uterus 
may produce reflexlya spasmodic contraction of the vessels. Renal and 
hepatic functions depend upon the amount of blood flowing through the 

394 



DISEASES OF PREGNANCY. 395 

organs, and are lessened by the diminished circulation, however pro- 
duced. In short, the pregnant woman is exposed to an increase of 
waste plus diminution of excretion. Ordinarily this increase of the 
demands made upon the eliminative organs results in their organic 
hypertrophy ; but there are certain women who suffer from habitual 
deficiency of excretion, and whose liver and kidneys do not respond 
when called upon for more work ; in such cases further interference 
through pressure has disastrous results. 

There are many facts which show there is nothing fanciful about the 
statements made in the preceding paragraph. Van de Velde demon- 
strated by experiments upon rabbits that there is an increase of the 
toxicity in the blood obtained from pregnant women ; Charpentier's 
inoculation-tests also prove the same. When symptoms of toxaemia 
appear the toxicity of the blood is found to be greater : the urine of 
pregnancy is more toxic than that passed by the non-pregnant woman, 
and in cases of toxaemia the toxicity of the urine diminishes in the same 
proportion as that of the blood increases. Auto-intoxication more fre- 
quently appears in those cases characterized by great distention of the 
uterus, as multiple pregnancies and hydramnios ; and, finally, death of the 
foetus or the artificial induction of abortion usually leads to a cessation 
of the toxic symptoms. 

Xatuee of the Poisons. Notwithstanding much investigation, the 
toxic material has not been isolated, and this part of the subject is in 
confusion. Tissue-waste forms toxins of alkaloidal nature and of com- 
plicated structure ; some of them are supposed to be potassium com- 
pounds. From the fact that bacteria have been found in the blood of 
toxic patients micro-organisms have been suggested as causing the 
disease ; but the probability is that the presence of the bacteria is the 
result, and not the cause, for toxic blood favors infection by supplying 
a favorable culture-medium. It is important to bear in mind that not 
one, but several toxins are to be held responsible, and that the poisonous 
principles may consist of intermediate products, such as creatin and 
creatinin. Pinard considers that the disorders of pregnancy are related 
to a physiologic insufficiency of the liver, and are really symptoms of 
hepatic break-down ; he characterizes the auto-intoxication of pregnancy 
as hepato-toxaemia. 

The effect of the toxins upon the tissues is that of irritation, especially 
marked in the case of the nervous system : the eliminative organs them- 
selves often are much disturbed either from excess of toxic material or 
from their attempt to deal with substances insufficiently prepared for 
excretion. Marked congestion of the liver and kidneys has been noted, 
and yet, even in the severest cases, lesions of structure may be slight or 
entirely absent. In some instances the toxins have produced a nephri- 
tis, the symptoms of which have appeared subsequent to the pregnancy. 
The action of the toxins upon the intestines and skin produces temporary 
irritation rather than pathologic change. 

Symptoms and Diagnosis. From what has been said, the symptoms 
and their rationale are easy to understand. The nervous system fur- 
nishes the most striking phenomena, consisting of headache, dizziness, 
tinnitus, disturbances of vision, and mental irritability : if these symp- 
toms reach a certain degree of severity, the pre-eciamptic stage appears, 



396 PATHOLOGY OF PREGNANCY. 

for a description of which the reader should consult the chapter dealing 
with Eclampsia. 

The symptoms arising from the digestive organs are nausea, vomiting, 
and, less frequently, salivation and diarrhoea. A general pruritus is 
not an uncommon evidence of the irritation of the skin, and in some 
instances bronzing of the surface may appear. Anaemia and jaundice 
are often present. Swelling of the feet and legs usually is associated 
with toxemia, but this condition may be quite independent of the auto- 
infection. 

The most important signs upon which the diagnosis rests come from 
urinalysis. The symptoms mentioned in the preceding paragraph are 
accompanied by a diminution of the amount of urea and total solids, 
although, as has been pointed out, the fault may not lie with the kid- 
neys, but with the insufficiency of the hepatic functions. While a 
description of the methods employed in urinalysis would be out of 
place, it may be well to mention some leading points. The analysis 
must always be based upon a twenty-four hour sample, in order to make 
the needful quantitative tests : the presence or absence of albumin is 
not the chief thing to be determined, but rather the efficiency of renal 
action. Albuminuria frequently is a feature of toxaemia ; but, on the 
other hand, there are severe cases in which no albumin has been de- 
tected. In the urine of pregnant women the urea may vary from 1.4 
to 2 per cent.; an amount less than 1 per cent, indicates a dangerous 
degree of toxicity of the blood. It is not implied that urea is the 
poison producing the unfavorable symptoms, but only that the urea- 
excretion constitutes a reliable clinical index of elimination. A micro- 
scopic examination must never be omitted in order to obtain information 
concerning the state of the kidney-tissues. 

Bouffe de Sanite-Blaise gives the following symptoms as diagnostic 
of hepato-toxaemia : 1 . A progressive diminution of the excretion of 
urea. 2. Increase in the proportion of uric acid. 3. The presence of 
such extractives as leucin, tyrosin, xanthin, and hypoxanthin. 4. Uro- 
biluria. 5. Alimentary glycosuria; i. e., if the patient ingests a fixed 
amount of glucose daily, a large portion of it will appear in the urine, 
because the liver is unable to perform its full glycogenic functions. 
6. Indicanuria. 7. Peptonuria. 8. Albuminuria. 

Prophylaxis. An appreciation of the importance of avoiding the 
dangers involved in toxic conditions makes this part of our subject of 
great importance. Prophylaxis consists in limiting the amount of 
waste-matter and in providing for free elimination. Careful attention 
to the details set forth in the chapter on Hygiene and Management of 
Pregnancy constitutes a great part of the prophylaxis. 

The diet should be simple, and should not include a large amount of 
meat. It may consist of lamb, mutton, fish, oysters, raw and cooked 
fruit, together with the lighter vegetables : pastry sweets, cheese, and 
rich sauces or gravies should be prohibited. Some of the cereals and 
whole wheat-bread are useful in overcoming a tendency to constipation. 
It is better for the patient to take several light meals than to overload 
her stomach at any one time. The intelligent physician will have no 
trouble in furnishing his patient with a written dietary suitable both to 
her needs and inclinations. Milk is extremely useful wdien it agrees, 



DISEASES OF PREGNANCY. 397 

and the addition of Vichy or soda-water will make it more palatable. 
Tea and coffee should not be taken more than once a day, and should 
be forbidden entirely if there are signs of digestive disturbance. The 
physician should insist that his patient drink water freely, and it is well 
to give definite directions on this point, as most women habitually take 
too small an amount of fluids. The patient may gradually be induced 
to take from one to two quarts in the twenty-four hours ; lemonade or 
the effervescing waters may be used freely ; it is often a good plan to 
give the patient a simple tablet to dissolve in the water, so that she may 
be impressed with the importance of the treatment. 

Pains must be taken that the patient has a daily evacuation from the 
bowels. The diet and free use of fluids will do much toward accom- 
plishing this end ; but, if necessary, some simple laxative, such as 
cascara or compound liquorice powder, may be prescribed ; in certain 
cases enemata are more satisfactory than the administration of drugs by 
the mouth. Elimination through the skin is promoted by frequent 
bathing, following by gentle friction with a rough towel and an occa- 
sional use of the cabinet. As the lungs play an active part in elimin- 
ation, the patient should be in the open air several hours a day, and. 
should avoid all crowded assemblies where the ventilation is bad. 
Pressure upon the body should be diminished by wearing the clothing 
as loose as possible ; the underclothing should be of flannel. 

The supervision of the urinary secretion is the most important part 
of prophylaxis. Urinalysis should be performed every two weeks, and 
on every occasion when there arise symptoms ; only in this way can we 
get early warning and take steps to prevent the development of serious 
danger. 

Treatment of the Toxic Condition. The appearance of nerv- 
ous symptoms in conjunction with diminution of the amount of urea 
and solids, as shown by urinalysis, calls for prompt and energetic treat- 
ment. The diet must at once be restricted to milk, except in the mild- 
est cases, in which bread, fruit, fish, oysters, and gruels may be permit- 
ted. Free movements of the bowels must be evoked by the use of 
calomel, sulphate of magnesium, or jalap. The following formula for 
an enema is mentioned by Davis, and is often efficient : 

Magnesium sulphate 2 ounces ; 

Glycerin 2 " 

Spirit of turpentine % ounce; 

Castile soapsuds 1 quart. 

The dose of the purgative must be regulated to the needs of the case, 
and it should be remembered that too active catharsis may bring on 
contractions of the uterus. 

Hot-air baths or hot packs, combined with the free administration of 
water, are the best means for aiding elimination through the skin and at 
the same time for promoting the flow of blood through the kidneys by 
relieving venous congestion, profuse sweating often being followed by 
an increase in the amount of urinary secretion. Grandin advises hot 
saline irrigation of the bowel, eight to ten gallons of a 1 per cent, solu- 
tion being employed ; this is very useful when the patient is vomiting, 
and so cannot retain w T ater given by mouth. Hypodermocleisis also is 



398 PATHOLOGY OF PREGNANCY. 

recommended, as well as high-up injections into the bowel of small 
amounts of normal salt solution frequently repeated. 

Renal functions may be stimulated by small doses of calomel, which 
drug may haye some effect upon the hepatic activity, and also by the 
use of infusion of digitalis. Dry cups help to relieve renal congestion, 
and nitroglycerine is recommended for cases in which a spasmodic state 
of the vessels is supposed to be present. Diuretics containing potash 
should not be employed, as it has been suggested that some of the 
poisonous products may be combinations of potassium. To stimulate 
oxidation, inhalations of oxygen may be tried. 

When there are great irritability and restlessness the administration 
of chloral per rectum may have a soothing effect ; but the main reliance 
must be upon removing the toxins, and not upon drugs which may 
both mask the symptoms and lock up secretion ; of the succedanea of 
opium, only codein is allowable. 

If the efforts to promote excretion are successful and the symptoms 
disappear, the case still calls for constant watchfulness on the part of 
the physician, who must carry out every detail described under the head 
of prophylaxis. Patients who have once suffered from toxaemia are 
liable to recurrences of the condition either later in the pregnancy or in 
a subsequent gestation. Anaemia is frequently the result of the action of 
toxins upon the blood, and demands the administration of iron and arsenic. 

There are some cases of toxaemia in which the symptoms increase in 
severity in spite of the most intelligent treatment, so that we are obliged 
to employ our final resource, namely, artificial termination of the preg- 
nancy. Indications for the induction of abortion are continued vom- 
iting, great weakness, and the development of the prodromata of 
eclampsia. Reliable counsel should be sought before so decided a step 
is taken. In conclusion, we wish to say that since the causes and results 
of toxaemia may have been understood and prophylaxis attended to 
there has been a decrease in the frequency and severity of the diseases 
of pregnancy. 

Albuminuria. 

Although albuminuria is said to exist in 5 per cent, of all pregnancies, 
there are but two conditions in which it is of special significance : First, 
when it is caused by an excess of toxins passing out through the kidney- 
tissues, associated with diminished excretion, as described in the pre- 
ceding paragraphs. Second, when the albumin is found in conjunction 
with tube-casts and is a part of the evidence of nephritis. 

To account for the cases of albuminuria not falling under these two 
heads various explanations are offered, all of which assume that the 
circulation through the kidneys is impeded by some condition arising 
from pregnancy. AVe know that the pressure from ovarian or uterine 
tumors often causes a temporary albuminuria ; the tumor of pregnancy 
may act the same way, and we are not surprised to find that in a large 
proportion of the cases the albuminuria does not appear until the later 
months of gestation, when the intra-abdominal pressure is greatest. 
Any condition which causes an extra degree of uterine enlargement, 
such as multiple pregnancies or hydramnios, predisposes to albuminuria ; 
primiparae, especially those with rigid abdominal walls, frequently have 



DISEASES OF PREGNANCY. 399 

albuminuria during the latter half of pregnancy. On the other hand, 
it is only fair to mention that Allbutt does not believe in pressure as a 
cause for renal disturbance, on the ground that the veins of the kidney 
are not easily pressed upon, and that albuminuria is often absent when 
the intra-abdominal pressure seems to be very great. Allbutt thinks 
that poisons absorbed from the intestinal tract are responsible for the 
kidney-disturbance. The circulation in the kidneys may be impeded 
from other causes than pressure, among which may be mentioned a spasm 
of the vessels due to reflex stimulation coming from the pelvis or from 
exposure to wet and cold ; but these etiologic factors are questionable 
and of trifling importance. The way in which the disordered circulation 
leads to albuminuria is not perfectly clear, but there probably results 
some interference in the vital processes of the cells allowing the albumin 
to pass out. We must bear in mind that albumin is not a normal con- 
stituent of the urine, and even if no morbid symptoms are present its 
appearance demands the attention of the physician. Hemorrhages into 
the placenta have been observed in albuminuric cases ; they probably 
are dependent upon conditions underlying the albuminuria. 

Diagnosis. "With proper attention to the care of the pregnant woman 
the physician never can overlook the presence of albumin in the urine ; 
the ordinary chemic tests are all that are necessary for diagnosis. The 
important point is to be certain that the albumin comes from the kidney, 
as a great many gravid women suffer from a slight leucorrhoea, which 
may contaminate the urine and invalidate the conclusions. In cases of 
doubt the surest way is to draw a specimen of urine by catheter, using 
all clue aseptic precautions ; or else direct the patient, before urinating, 
to take a vaginal douche and afterward introduce a small tampon of 
absorbent cotton into the lower portion of the vagina ; the cotton should 
have a string attached, so that the patient can remove the tampon. The 
presence of a cystitis may be excluded by the history of the case and by 
a complete urinalysis. As the significance of albumin depends upon its 
relation to the excretion of urea, all cases of albuminuria must be 
frequently and thoroughly examined. 

Treatment. Albuminuria itself does not call for any special treat- 
ment except when a sign of some serious condition. The treatment 
of toxaemia has been discussed. A slight albuminuria in the latter 
months of pregnancy, even if associated with oedema of the lower 
extremities, need not be looked upon as serious in the absence of other 
symptoms. Where the albuminuria seems dependent upon a weak cir- 
culation the cardiac stimulants are indicated as in the non-pregnant state. 

Disorders of Digestion. 

Nausea and Vomiting of Pregnancy. A certain degree of nausea and 
vomiting is considered by many a part of the physiologic processes of 
early pregnancy : slight gastric disturbances are mentioned as having 
a certain diagnostic value. What is known as simple vomiting is that 
form of disorder appearing near the beginning of gestation and ceasing 
about the middle ; its symptoms are not severe nor its consequences 
serious. A second form is known as hyperemesis gravidarum, perni- 
cious or uncontrollable vomiting, and it differs from the first in being 



400 PATHOLOGY OF PREGNANCY. 

more severe and of longer duration ; its evil results are implied in the 
term pernicious. There are many cases in which the first form passes 
gradually into the second, so that a border-line is difficult to fix. On 
the other hand, many women pass through pregnancy with no disturb- 
ance of their gastric functions, and modern authorities are reaching the 
conclusion that nausea and vomiting in pregnancy are pathologic and 
not physiologic phenomena, and that the two forms depend upon the 
same general causes and differ only in degree. 

Simple Vomiting. In rare instances the symptoms begin a few days 
after conception, but more frequently not until the end of the first month 
coincident with suppression of the menses. The nausea and vomiting 
frequentlv are present on waking in the morning, or may not come on 
until after eating breakfast. After one or two attacks of emesis the 
patient may be entirely relieved, take food regularly through the day, 
and go through the same performance the next morning. In the 
mildest cases there is nothing but a little temporary nausea every morn- 
ing which passes off by noon. In the severe forms more or less vomit- 
ing continues throughout the twenty-four hours, attacks being brought 
on by the ingestion or mere sight of food, and also by physical exertion 
or strong emotion of any kind. There are exceptional cases, which 
may be classed as nocturnal, in which the patient is afflicted with emesis 
after retiring at night. In the case of early morning vomiting the 
ejected matter consists of mucus, usually of a strongly acid reaction ; 
at other times partially digested food appears in the vomitus ; if the 
emesis is prolonged, the ejected material is stained with bile. 

The features which entitle this form of nausea to be classed as simple 
are, first, the tendency to spontaneous cure at the fourth month when the 
uterus rises out of the pelvis, and, second, the non-impairment of the 
woman's nutrition to any dangerous extent. 

Hyperemesis Gravidarum. The vomiting is classed as pernicious 
when the nutrition of the mother and child suffers and the affection 
persists. The disease may be divided into three stages : 

First Stage. This stage begins with the features of simple vomiting 
and grows progressively more severe. The vomiting appears upon 
every attempt to take either solid or liquid nourishment, with the result 
that the patient soon develops an aversion to food of all kinds. At 
first the character of the vomitus is as described in the remarks on simple 
vomiting ; but later streaks of blood and masses of coffee-ground-look- 
ing material appear in the ejecta, the latter being the result of blood- 
disintegration. Ptyalism and profuse diarrhoea may be associated 
symptoms, and in the movements of the bowels the coffee-ground 
material may appear. The constant vomiting, now independent of any 
efforts at taking food, produces a burning sensation beneath the sternum, 
and the epigastric region becomes extremely sensitive to pressure. Some- 
times there are lulls in the course of the disease, during which the 
patient takes and retains food, and the physician is deluded into the 
belief that recovery has set in. This apparent improvement is only 
temporary, however, and as the disease progresses the patient is unable 
even to raise her head from the pillow without being nauseated ; emaci- 
ation becomes apparent ; there is a feeling of lassitude or weakness ; 
the pulse is rapid and the temperature often subnormal. 



DISEASES OF PREGNANCY. 401 

Second Stage. A fever, presumably of toxic origin, marks the access 
of this stage : at first the elevation of temperature occurs only at night, 
but later it is continuous, reaching as high as 103° F. ; the pulse-rate 
may be 140. The symptoms now resemble those of pernicious anaemia, 
there being the coffee-ground vomit and dejecta, jaundice, sordes upon 
the teeth, and purpuric extravasations. The weakness of the second 
stage is more pronounced, so that even slight efforts are attended with 
syncope. The reflexes usually are much increased ; the urine is scanty 
in amount, of high specific gravity, and usually contains albumin and 
casts. There may be present abnormal constituents, the same as those 
mentioned under the head of hepato-toxaemia. The drain of fluids 
from the body, due to the vomiting and diarrhoea, causes the patient to 
complain of great thirst. 

Third Stage. Death frequently cuts short the case before this stage 
is reached. The peculiar feature of this stage is the cessation of the 
vomiting owing to the utter exhaustion of the vomiting-centre. The 
rise of temperature is continuous, but the pulse shows the sign of 
approaching collapse by becoming weak, rapid, and irregular. The 
meutal state is usually one of apathy, though occasionally there are 
delirium and delusions. Coma precedes the fatal issue. 

Causes of the Nausea and Vomiting of Pregnancy. All 
explanations of the gastric disturbance of pregnancy must take into 
account both the condition of the nerve-centres and peripheral irritation. 
Even when the vomiting-centre is in its normal state we can understand 
how it may be stimulated into activity by a powerful reflex influence, 
and there is an abundance of clinical evidence to prove that pathologic 
uterine conditions may be efficient reflex sources of gastric disorders. 
At the beginning of pregnancy the woman's nervous system often is in 
a condition of unstable equilibrium, possibly due to circulatory changes, 
so that such physiologic stimuli as distention and change in the position 
of the uterus may disturb the vomiting-centre and lead to those simple 
forms of stomach irritability. After a few weeks or months the nervous 
system becomes adjusted to the new conditions, and physiologic stimuli 
no longer produce pathologic manifestations. More powerful reflex 
action will result when the uterine modifications of pregnancy are inter- 
fered with by abnormal pelvic conditions, such as adhesions binding 
down the fundus or by a retroversion allowing the organ to become 
crowded beneath the promontory of the sacrum : in these pathologic 
conditions we do not need to assume the existence of an oversensitive- 
ness of the nerve-cells, but when such is the case there will naturally 
be an aggravation of all the symptoms. When we come to those severer 
forms of vomiting classed as pernicious, the modern theories lay par- 
ticular stress upon those conditions which render the nerve-centres irri- 
table, and which are included in the term auto-intoxication. Several 
writers claim that hyperemesis is a direct evidence of auto-intoxication, 
and particularly of hepatic break-down. If the foetus dies in utero, 
the trouble usually ceases. Honvitz points out that pernicious vomiting 
occurs at a time when the uterus is not distended ; this fact does not 
invalidate the theory that auto-intoxication is the underlying element, 
but merely shows that toxaemia may occur independently of much in- 
crease of intra-abdominal pressure. Dirmose considers that intestinal 

26 



402 PATHOLOGY OF PREGNANCY. 

toxaemia is the underlying evil. At the present stage of our knowledge 
it is unprofitable to discuss the question whether the hyperemesis of 
pregnancy is produced by one form of poisoning or another as long as 
we bear in mind that there is a practical unanimity of opinion that 
hyperemesis, in the vast majority of cases, is a symptom of toxaemia and 
not really a separate disease. The toxins act in two ways : first, they 
are themselves irritants ; second, they make the centres extremely sen- 
sitive to all reflex stimuli. It is a significant fact that those pregnant 
women whose elimination is habitually active seldom suffer from even 
the mild forms of gastric disturbance. It is probable that most cases 
of simple vomiting are at first entirely dependent upon reflex causes, 
but after a time the frequent attacks of emesis may produce such dis- 
turbances of digestion and elimination as to lead to toxaemia : thus, the 
simple form gradually may pass into the pernicious. 

Diagnosis. The main point at issue in the diagnosis is whether the 
nausea and vomiting are related to the pregnant condition or independent 
of it. A thorough pelvic examination should be made and abnormal 
sources of irritation sought for ; the urine should be measured and com- 
pletely examined. The evidences of complicating diseases, such as 
gastric ulcer, gastric cancer, cirrhosis of the liver, or nephritis, must be 
looked for ; coffee-ground material in the vomit or dejecta should be 
examined for disintegrated blood-corpuscles, in order to diagnose the 
stage of the affection. 

Prognosis. The term simple vomiting implies the presence of an 
affection the prognosis of which is good ; as has been stated, this form 
of the disorder tends to spontaneous cure without injury to the mother 
or child. In the pernicious form of vomiting the prognosis is always 
grave, the mortality being given from 30 per. cent, to 60 per cent. 
Probably, treatment based on the theory of toxaemia will give us more 
favorable results and render the prognosis less serious. The affection 
may lead to a spontaneous abortion, with a resulting cure ; but such an 
outcome is not at all common. The most unfavorable symptoms are 
emaciation, feeble pulse, epigastric pain, coffee-ground vomit, and a low 
elimination of urea. 

Treatment. The possibility of a toxic element underlying the 
nausea and vomiting of pregnancy should always lead the physician to 
investigate even slight disturbances of the stomach when appearing in 
gravid patients ; he must look upon all pronounced forms of digestive 
disorders as pathologic. Another influence of modern ideas upon this 
subject is to impress upon us the comparative uselessness of drugs and 
greatly curtail the long list of medicines found in all the older text- 
books. We cannot divide the treatment into that of simple and per- 
nicious vomiting, because clinically one form fades into the other ; all 
treatment is directed toward diminishing the sources of peripheral irri- 
tation and removing the undue susceptibility of the nerve-centres. 

1. Treatment Directed to Removing Sources of Peripheral Irritation. 
In severe cases it is best to keep the patient in bed and free from all 
noise or excitement ; sometimes even light must be excluded from the 
room. In the mild forms of morning sickness the woman may escape 
the vomiting if she eats her breakfast in bed and remains quiet until 
noon : in the severest cases it is necessary to keep the patient in bed in 



DISEASES OF PEEG NANCY. 403 

order to save her strength, as well as to keep her free from disturbing 
influences. An important part of the treatment falling under this head 
consists in attention to the patient's pelvic conditions. At the onset of 
the affection a careful bimanual exploration of the pelvis should be per- 
formed, so that no abnormality may remain undetected. If the uterus 
is found to be displaced backward and non-adherent, the bladder and 
rectum should be emptied and the womb replaced by bimanual manipu- 
lation : in difficult cases anaesthesia may be necessary. After the uterus 
is in proper position a pessary should be introduced and worn until the 
organ has become too large to fall into the pelvis again. When the 
uterus is so large that the fundus will not readily swing by the prom- 
ontory of the sacrum the treatment may require several sittings, each 
gain in elevation being maintained by means of a snug vaginal tampon. 
The knee-chest position may be of material aid. In cases which have 
advanced so far that symptoms of incarceration have appeared and treat- 
ment has failed, M. I). Mann advises abdominal section, followed by 
manual elevation of the fundus. In displacement complicated by the 
existence of pelvic adhesions, tamponing the vagina with cotton or wool 
is indicated; the upper tampons should be soaked with a 10 per cent, 
solution of ichthyol in glycerin. The medicament will promote a free 
discharge of serum from the tissues, relieving congestion and stimulating 
absorption ; the tampon may be allowed to remain for forty-eight hours 
at a time if the cotton be sterile and well sprinkled with iodoform. It 
is noticed that this treatment often affords relief from vomiting even 
before the conditions are entirely restored to normal. If local treatment 
fails to free the uterus, vaginal section should be performed and the 
adhesions broken by the finger introduced through the posterior cul-de- 
sac. When the uterus is anteflexed and crowded down into the pelvis, 
Hewitt recommends the use of an air-ball pessary, which is inflated 
after its introduction into the pelvis ; tamponing may be substituted for 
the pessary. 

In some of the cases nothing pathologic can be discovered other than 
a cervical discharge associated with more or less erosion about the 
external os. In these instances local applications to the uterus may be 
tried. The cotton-w T rapped applicator, after being dipped in iodine or a 
solution of silver nitrate (30 grains to the ounce), is inserted as far as 
the internal os and the cervical endometrium thoroughly treated ; the 
portio vaginalis also should be painted with the solution. A contracted 
or rigid condition of the tissues about the cervical canal may be the 
starting-point of undue stimulation, and has led to the treatment by 
dilatation. Under anaesthesia a steel dilator is introduced and the lower 
portion of the canal dilated to a degree sufficient for the admission of 
the finger ; instead of the steel dilator, strips of iodoform gauze are 
sometimes employed. All local measures must be carried out with 
attention to aseptic details, and the family or friends should be informed 
that the treatment, especially dilatation, may result in an abortion. 

2. Treatment Directed to Removing the Irritability of the Nerve-centres. 
In the mild form of simple vomiting it is justifiable to employ some of 
the remedies which diminish reflex action, such as chloral and sodium 
bromide ; but in those cases showing signs of the pernicious form the 
dietetic and general treatment is directed toward overcoming the condi- 



404 PATHOLOGY OF PREGNANCY. 

tion of toxaemia resulting from deficient elimination. It must be re- 
membered that the vomiting and diarrhoea may represent efforts at 
excretion, and therefore the stomach and bowels are not the points for 
therapeutic attack. For the details of the antitoxic treatment the reader 
is referred to the article on Toxaemia. 

Dietetics. This department is regulated by the condition of actual or 
threatened toxaemia, but we must remember that prolonged vomiting will 
leave the stomach extremely irritable for a time and call for a light and 
easily digested diet. Milk in some form is our main reliance, but beef 
peptonoids or somatose may be tried ; sometimes the patient will retain 
the articles of food which seem to be most unsuitable. When the stomach 
shows itself absolutely intolerant, rectal alimentation must be used : 
four to six ounces of nutrient material may be injected every four or six 
hours ; in such cases there should be daily irrigations of the bowels with 
warm salt solution. 

Drugs. Drugs should be used with extreme caution, except such as 
are of aid in the eliminative treatment ; intestinal antiseptics may be 
employed on the theory of intestinal toxaemia being the particular fault. 
The following drugs may be mentioned as being extensively used : 
cocaine in doses of -| grain ; oxalate of cerium, gr. x, three or four times 
a day ; dilute hydrocyanic acid, wine of ipecac, and carbolic acid given 
in drop doses well diluted and frequently repeated. Washing out the 
stomach through a tube is sometimes an excellent measure ; at the close 
of the lavage some water having calcined magnesia in suspension may 
be left in the stomach with advantage. Morphine or opium should 
never be employed, as the result is a masking of symptoms and a locking 
up of secretions. As a rule, medication addressed to the stomach is 
beginning at the wrong end of the trouble, a fact well attested by the 
interminable lists of drugs given in the books and handed down through 
force of habit. If a gastric catarrh develops, the appropriate treatment 
should be instituted. In the advanced stages of pernicious vomiting a 
free use of the cardiac stimulants is demanded. 

If, in spite of all efforts of treatment, the case becomes progressively 
worse, there is no resource left but the induction of abortion or prema- 
ture labor. This operation should never be performed without the 
advice of counsel ; but, on the other hand, the procedure must not be 
put off until the patient is so weak that she cannot stand the necessary 
strain of its performance. No case should be allowed to advance beyond 
the inception of the second stage, or when the unfavorable symptoms 
mentioned under prognosis appear ; the character of the pulse must be 
the important guide. In many instances, even after the uterus has been 
emptied, energetic eliminative measures must be continued for a time, 
before the vomiting ceases. 

Pytalism. A profuse secretion from the salivary glands may be a 
source of great annoyance during the early part of pregnancy, and in 
extreme cases the quantity of saliva may amount to one or two quarts 
during the twenty-four hours. The latest authorities are inclined to 
include ptyalism among the phenomena of auto-intoxication, there being 
some toxin which stimulates the salivary glands and is eliminated in the 
saliva. It may be that the hypersecretion, instead of being excretory, 
is simply the result of the irritation of oversensitive nerve-centres. The 



DISEASES OF PREGNANCY. 405 

symptoms consist in constant flow from the glands, which necessitates 
frequent expectoration, or, in severe cases, the wearing of a napkin to 
catch the fluid constantly dribbling from the angles of the mouth. 
Ptyalism usually ceases by the fourth or fifth month ; in rare cases it 
has continued throughout the pregnancy and for several months subse- 
quently. 

Treatment is not very satisfactory, except when removal of the 
toxaemia puts a stop to the disorder. Belladonna and astringent mouth- 
washes are sometimes used ; a weak galvanic current applied to the 
salivary glands has been recommended. 

Dental Caries. There is no question that pregnancy predisposes to 
decay of the teeth. The causes ascribed are the demands upon the 
maternal organism for lime-salts and the action of altered buccal secre- 
tion ; at the beginning of pregnancy the woman should have her teeth 
examined and follow the advice of a dentist as to their care, thus 
diminishing the risk of suffering from facial neuralgia, which is so 
often aroused by carious teeth. After each meal it is advisable for her 
to use dental floss and rinse the mouth with some alkaline mouth-wash. 

Pyrosis. It is not uncommon for a pregnant woman to be troubled 
with eructations of a strongly acid fluid, accompanied with a sensation 
of burning in the epigastrium. This is a reflex disorder of the same 
nature as the vomiting and nausea. The treatment is removal of any 
exciting cause, attention to elimination, and the use of alkalies, such 
as bicarbonate of sodium and aromatic spirits of ammonia. A useful 
remedy is a gastric sedative powder suggested by C. G. Stockton for; 
cases of hyperchlorhydria ; the formula is as follows : cerium oxalate, 
1 part ; bismuth subcarbonate, 2 parts ; and light magnesia, 4 parts. 
Of this, one or two teaspoonfuls should be stirred into a third of a glass 
of water and taken when the symptom appears. 

Pica or Malacia. These are terms describing a peculiar craving for 
unnatural articles of food, such as coal, chalk, dirt, etc. In the mildest 
forms of the affection the patient merely displays a fondness for varieties 
of food which are disliked when she is in the non-pregnant state. 
Sometimes this craving is a part of other gastric disorders, but it usually 
may be regarded as of psychic origin. 

Treatment. There is no special treatment except to make efforts 
toward preventing the patient from injuring herself. 

Anorexia, Diarrhoea, and Constipation, and similar disorders do not call 
for extended comment ; they are usually controlled by proper atten- 
tion to the hygiene of pregnancy. Diarrhoea as a symptom of toxaemia 
has been mentioned. The increased intra-abdominal pressure often 
causes constipation, which should be overcome with regulation of the 
diet and administration of laxatives. 

Disorders of Circulation. 

Palpitation. This is very common at some time during pregnancy ; 
it maybe reflex or the effect of direct pressure upon the diaphragm ; it 
is more often experienced in the latter part of pregnancy and when the 
uterus is overdistended. In some cases it is of srastric origin or related 
to the condition of amemia or hysteria. 



406 PATHOLOGY OF PREGNANCY. 

Treatment. The treatment consists of removal of the cause when 
possible : aromatic spirit of ammonia constitutes a useful remedy for 
the time being. 

Syncope. Fainting may be associated with palpitation, and is usually 
of purely nervous origin. 

Treatment is the same as in the non-pregnant. 

Hemorrhoids and Varicose Veins. As these affections result from me- 
chanical pressure, they are met with in the latter part of pregnancy ; 
the veins of the anal region, the lower extremities, and vulva are the 
vessels most often enlarged. Gestation is apt to have pronounced effect 
upon pre-existing varicosities ; anaemia, by interfering with the nutrition 
of the vessel-walls, acts as a contributing cause. 

The treatment is merely palliative, as the underlying cause cannot 
be removed until labor occurs. Hemorrhoids are treated by the avoid- 
ance of constipation and the application of soothing ointments, such as 
the injection of a small amount of linseed oil or the following : 

Morphine gr. v. 

Muriate of cocaine gr. x. 

Calomel gr. xl. 

Vaseline 1 ounce. 

Apply locally night and morning. 

If there is much itching, a drachm of menthol may be added to the 
above. For the varicose veins of the legs elastic bandages may 
be used; occasionally patients are confined to bed for the last few 
weeks of pregnancy, owing to the great swelling of the lower limbs. 
There is some danger of external rupture of the vessels in aggravated 
cases, and the patient should be taught how to apply pressure in order 
to control hemorrhage, which may be very severe : when rupture takes 
place into the tissues about the vulva a hematoma of large size may be 
produced. The hematoma is best left alone, as absorption usually takes 
place ; in case of suppuration the tumor should be incised, the clots 
washed out, and the cavity packed with gauze ; the packing is renewed 
every forty-eight hours until healing takes place. The treatment of 
vulvar haematomata during labor is elsewhere described. Radical meas- 
ures for cure of varicosities are best postponed until after labor, as they 
are apt to produce uterine contractions. 

Anaemia. \Ye can readily understand how important are the blood- 
changes of pregnancy when we appreciate the demands made upon the 
maternal blood ; upon this fluid tissue all the burdens of nutrition must 
fall. Like other tissues, the blood increases in order to meet the new 
requirements laid upon it ; at first the increase is chiefly in its watery 
constituents, but later it becomes richer in both quantity and quality ; 
toward the end of pregnancy the blood is said to contain an excess of 
fibrin. There are two ways in which anaemia may arise during preg- 
nancy ; first, there may be a failure of the necessary modifications to 
meet the increased demand, thus producing a relative insufficiency of 
the blood ; second, the presence of toxic matter may produce a deterio- 
ration of the blood-corpuscles. Bad hygienic conditions are potent 
predisposing causes. In the study of the anaemia of pregnancy we 
cannot fail to be impressed with that peculiar feature of pregnancy, 



DISEASES OF PREGNANCY. 407 

namely, the demand for certain modifications, and at the same time the 
development of conditions which hamper their production. 

The anaemia of pregnancy calls for treatment, as the disorder may 
have marked effect upon both mother and child : its symptoms are the 
same as when existing in the non-gravid patient, but they are often 
masked by evidences of other and underlying disorders. It is claimed 
that a simple anaemia of pregnancy may in some cases develop into the 
pernicious form. 

The treatment consists in careful regulation of the food and excre- 
tions of the patient, as well as attention to all the hygienic conditions. 
Iron, arsenic, and strychnine are the drugs indicated ; bone-marrow is 
valuable in most cases. When other means of relief fail and the disease 
progresses so as to threaten life, the induction of premature labor must 
be considered. 

Disorders of the Respiratory System. 

The disorders of the respiratory system during pregnancy are unim- 
portant and may be dismissed with few words. There may be a reflex 
cough, which is to be regarded in the same light as nausea and vomiting. 
\Vhen there is no trouble with the lungs or bronchi the treatment is to 
be addressed to the nervous system ; the cause of the reflex stimulation 
should be removed if possible ; the valerianates and codeine are useful 
in the way of medication. 

Dyspnoea. This usually is a symptom of pressure of the gravid uterus 
upon the diaphragm, appearing late in pregnancy and intensified by 
overdistention of the uterus from hydramnios or twins. 

Treatment consists in directing the patient to avoid all excitement 
or overexertion, in order to lessen the demands made upon the respira- 
tory organs. 

Disorders of the Nervous System. 

Xervous symptoms have been prominent symptoms of the diseases 
already considered. Pregnancy makes great demands upon the maternal 
nervous system, and at the same time exposes the centres to deleterious 
influences such as were discussed in speaking of toxaemia. 

Mental Affections. Hysteria and slight alterations of the nervous 
system are not uncommon during gestation, and probably in most in- 
stances denote increased nervous susceptibility merely or want of equilib- 
rium. The. fact that slight mental changes are expected during preg- 
nancy has resulted in a failure to diagnose incipient insanity. Insomnia, 
irritability of temper, and an alteration of the disposition may represent 
the prodromal stage of insanity. In investigating the relation between 
pregnancy and nervous diseases, J. W. Putnam found reports of many 
cases of gestation-insanity, although the disorder forms but a small per 
cent, of asylum cases. One hundred and twenty-five out of one hun- 
dred and seventy-five of Tuke's cases occurred in primiparae, and Savage 
considers that insanity is more frequent when the offspring is male. 
The type of mental disturbance is usually melancholic, and a suicidal 
tendency shows itself in about one-half the cases. A growing antipathv 
toward the husband is a common feature of the disease. 



408 PATHOLOGY OF PMEGXASCY. 

Treatment. There is nothing peculiar about the treatment of 
mental diseases during pregnancy, but as toxaemia is suggested as an 
underlying cause the maintenance of elimination is important. AY lien 
suspicious symptoms appear the case should be watched closely, as an 
entirely unexpected attempt at suicide has been successful through want 
of observation and precaution on the part of the medical attendant. 
The prognosis for recovery after labor is good. 

Neuralgia. This painful affection constitutes a not infrequent cause 
of complaint among pregnant women. The pain is most often situated 
in the face or pelvis. The causes are auto-intoxication, dental caries, 
abnormal uterine positions, pelvic adhesions, and the presence of hard- 
ened feces ; anaemia may be an important predisposing element. 

Treatment consists in removing the cause and underlying con- 
ditions. A certain amount of discomfort from pressure in the pelvis or 
distention of the abdominal walls is unavoidable. The suffering may 
be relieved by the administration of coal-tar products or codeine : where 
there are distinct painful areas on the skin counterirritation may prove 
of benefit. In severe cases morphine must be administered hypo- 
dermatically. 

Herpes. This unpleasant affection is sometimes developed during 
gestation ; Hardy mentions a patient who was afflicted during nine out 
of ten pregnancies. The symptoms are the same as those characteristic 
of the disease among the non-pregnant. Although the affection does 
not show a tendency to cut short the course of the gestation, it produces 
a marked depression of the vital powers and calls for supporting meas- 
ures. That there is usually prompt and spontaneous recovery when 
labor occurs suggests trial of vigorous eliminative treatment. 



PART VI. 

PATHOLOGY OF LABOR 



CHAPTEE XIX. 

ANOMALIES OF THE MECHANISM. 

Dystocia is the term applied to labor which, without artificial assist- 
ance, would be difficult or impossible, or would be attended with danger 
to mother or child. Bhis the opposite of Eutocia, which denotes normal 
labor terminating safely and easily without artificial aid. 

Every case of labor is a mechanical problem in which the three main 
factors are (1) the expelling force, (2) the foetus which is to be expelled, 
and (3) the resistance of the parturient canal, which must be overcome 
before delivery can be effected. When the expelling force is sufficient, 
and there is no disproportion between the foetus and the maternal passages, 
labor proceeds normally. As the foetus descends through the parturient 
canal more or less adaptation takes place; the presenting part moulds 
somewhat to the shape of the canal, while the maternal soft parts stretch 
and open out to make way for it, till finally it is expelled spontaneously, 
without serious damage to itself or to the mother. So long, then, as 
these three main factors are properly correlated, all goes well; but if 
their harmonious action be impaired, the normal mechanism of labor may 
be disturbed, and dystocia may be the result. The cause of the abnor- 
mal mechanism may be in any one of these three factors : the expelling 
force may be insufficient or excessive; the foetus itself may be unusually 
large or small, may be in a faulty attitude or may present in an unfa- 
vorable position ; the resistance of the maternal passages may be too 
great or too little. It is obvious, therefore, that in the management of 
a case of dystocia the recognition of the disturbing cause forms the 
basis of rational treatment, and should precede artificial assistance. 

Dystocia maybe most conveniently described, according to its causation, 
in three sections, as follows : 

1. Anomalies of the expellant forces : 
(a) Excess — precipitate labor. 

(6) Deficiency — delayed labor — inertia uteri. 

(c) Spasm and irregularity - — rigid os and cervix — tetanus uteri. 

2. Anomalies of the passages : 

A. Hard parts — pelvic deformities. 

Influence on pregnancy and labor; frequency. 

( 409 ) 



410 PATHOLOGY OF LABOR. 

Diagnosis — From previous history and physical appearance. 
From mechanism of labor. 
From head moulding. 
From physical examination — pelvimetry. 
(a) External measurements. 
(6) Internal measurements. 
Classification : 

Pelves — Normally proportioned, but abnormal in size. 
With anomalies of size, shape, inclination. 
With minor developmental peculiarities. 
Antero-posteriorly contracted. 
Obliquely contracted. 
Transversely contracted. 
Compressed. 
Spon dy lolisthetic. 

Distorted by injury, tumors, anchylosis of joints. 
With deformities due to spinal curvature. 
Individual forms particularly studied; relation to pregnancy and 
labor. 
B. Soft parts : 

Uterus — Developmental anomalies. 
Atresia of cervix. 
Rigidity of cervix. 
Impaction of cervix. 
Malposition. 
Sacculation. 
New growths. 

Stenosis and rigidity of vulva and vagina c 
Hematoma vulva?. 
(Edema vulvae. 
Labial abscess and cysts. 
Conditions of intestines. 
Conditions of bladder. 
Tumors and swellings of various tissues. 
3. Anomalies of the foetus : 
Malposition of the head. 
Occipito-posterior cases. 
Malpresentations : 

Face, brow, pelvic, transverse. 
Prolapse of the limbs. 
Anomalies of foetal development : 
Shortness of cord. 
Unduly ossified skull. 
Large size of foetus. 
Death of foetus. 

Enlargement of head or body by disease. 
Plural births. 
Monstrosities. 



ANOMALIES OF THE MECHANISM. 411 



1. ANOMALIES OF THE EXPELLANT FORCES. 

(a) Excess — Precipitate Labor. 

When uterine action is excessive the resistance of the maternal passages 
may be overcome violently or rapidly, and then labor is said to be pre- 
cipitate. The posture of the patient has an important influence upon the 
course and termination of such cases. In the dorsal or lateral position 
the pains are rarely strong enough to end labor so rapidly as to cause 
serious damage; but if the patient happens to be standing, walking, 
sitting, or squatting, a single violent pain may suffice to force the child 
completely through the passages. It may fall to the floor and be injured; 
the cord may be torn asunder and the placenta may be dragged from its 
attachments, or, remaining adherent, may pull the uterus along with it, 
causing inversion. If the patient happens to be sitting in a privy or 
water-closet, the child may fall into the cesspit or into the pan of the 
closet, and may perish before assistance can be procured. Not infre- 
quently the mother faints from shock or loss of blood, or she may become 
so bewildered and frightened that she does not realize what has happened 
until it is too late to save her child. Such cases sometimes give rise to 
important medico-legal questions, especially when the child is illegiti- 
mate and a charge of infanticide is laid. While undoubtedly it must be 
admitted that such cases of sudden delivery do happen occasionally, 
nevertheless it is very exceptional for labor to be so rapid that the patient 
has no warning of what is about to take place and has no time to seek 
assistance. As a rule, the first stage of labor is more or less normal in 
such cases, and it is only in the second stage that precipitancy occurs. 
If the membranes are tough and the amniotic sac descends very low 
before rupturing, then the sudden gush of water may sweep the pre- 
senting part violently down upon the perineum, and delivery may be 
completed at a single pain. It does not always happen that precipitate 
labor follows excessive uterine action. If the maternal soft parts do not 
yield to the expellent forces, but are rather provoked thereby to greater 
resistance, labor may be delayed, and the uterus may become exhausted 
by fruitless efforts, or may even rupture. Under such circumstances the 
child will probably perish, the placenta being compressed and the foetal 
circulation deranged by the prolonged uterine contraction. 

Causes. The chief predisposing causes are (1) an undue excitabilty of 
the sensory nerves of the uterine muscle, which frequently exists in ner- 
vous excitable women, ] and (2) previous inflammatory conditions of the 
uterus, such as an old endometritis. Debilitating conditions which relax 
the tone of the pelvic floor favor precipitate labor by diminishing the 
resistance which is to be overcome. Dysmenorrhea, oblique presenta- 
tions, pneumonia, and zymotic diseases (especially variola and scarlatina), 

1 Dr. Routh recently reported to the London Obstetrical Society a case of labor in a woman suffer- 
ing from complete paraplegia (traumatic) below the level of the sixth dorsal vertebra. The ouly 
sensation which the patient felt during a pain was a tight feeling at the epigastrium, causing her to 
hold her breath. Dr. Routh concludes that the act of parturition is partly automatic and partly 
reflex, and thinks that direct communication by means of the sympathetic between the uterus and 
the lumbar enlargement is essential to the regular and co-ordinate contraction and retraction of the 
uterus during labor. If this view be correct, it is obvious how powerfully uterine action may be 
influenced by causes acting through the sympathetic, and how frequently the true cause of abnormal 
uterine action may be found in derangements of the nervous system. 



412 PATHOLOGY OF LABOR. 

may be mentioned also as predisposing causes. Fear, anxiety, and pow- 
erful emotions are said to increase the force of uterine contractions, but 
it is probable that their action is not constant, and that undue exertion 
on the part of the patient, such as walking, is usually the exciting cause. 

Sequelae. The most important immediate consequences of precipitate 
labor are lacerations of the vagina, vulva, and perineum, partial or com- 
plete separation of the placenta, hemorrhage, inversion of the uterus, 
and delayed expulsion of the placenta. Violent contraction of the uterine 
muscle is apt to be followed by relaxation and atony, and hemorrhage 
may result. In the puerperium also many troubles may arise, such as 
oedema, retention of urine, hemorrhage, and septicemia. Violent strain- 
ing efforts in rare cases have produced emphysema of the throat, neck, 
and chest from slight lesions of the trachea or bronchi; but this usually 
disappears in a few days without treatment. 

The foetal mortality is greater than in normal labor. The child's head 
may be injured by being driven forcibly against the promontory of the 
sacrum, and the cranial bones may be furrowed or even fractured. The 
child may be asphyxiated by undue compression of the foetal head or of 
the cord or placental site. It may be injured by falling violently upon 
the floor, or it may perish by dropping into a cesspit or water-closet. 

Treatment. If a previous labor has been precipitate, or if the uterine 
action is manifestly excessive or violent, the patient should not be allowed 
to stand or walk about, or to sit upon the closet, especially during the 
second stage of labor, but should be kept in bed and made to lie on her 
side. To moderate the violence of the pains, a dose of chloral (grs. xx 
to xxx) may be given, or a hypodermic injection of morphia (gr. J), or a 
few whiffs of chloroform may be administered at the beginning of each 
paiu. The patient should be made to pant during her pains, and should 
not be allowed to hold her breath or bear down. Some authorities advise 
rupturing the membranes before the os is fully dilated. AVhen the 
pains of the first stage cause great suffering, some writers recommend 
painting the cervix with a solution of cocaine (4-10 per cent.). During 
delivery care should be taken to protect the perineum, the head being 
held back and prevented from descending too rapidly. Some authorities 
advise the application of forceps in order to give greater control over 
the head and prevent its too rapid descent and expulsion. Chloroform 
is invaluable at this stage. Great care should be taken in the manage- 
ment of the third stage of labor; plenty of time should be given for 
the placenta to separate, and the uterus should be kept under control 
for some time after the placenta has been expelled, in order to guard 
against subsequent relaxation. If the uterus does not contract well, or 
if it shows a tendency to relax, a copious hot intra-uterine douche 
should be given, followed by a hypodermic injection of ergot. The 
physician should not leave his patient until he is satisfied that the 
uterus is well contracted, and that there is no further danger of 
hemorrhage. 

(b) Deficiency — Delayed Labor — Inertia Uteet. 

When the uterine action is insufficient to overcome the resistance of 
the parturient canal labor is delayed, and the pains are said to be weak. 



ANOMALIES OF THE MECHANISM. 413 

The weakness of labor-pains is relative. Pains which would be strong 
enough for the iirst stage may be inadequate for the second stage. Pains 
which would be normal and efficient if the resistance were slight, may 
be inadequate, and, therefore, abnormal when the resistance is great. 
The true test of the weakness and inefficiency of labor-pains on the one 
hand, or of their strength and efficiency on the other, is the advance of 
labor ; whenever they are too short or too feeble to secure the normal 
progress of labor, they are weak. Mere sluggishness of uterine action, 
however, is not to be confounded with weakness. Sluggish pains recur 
at abnormally long intervals, yet they may be strong and efficient never- 
theless. In estimating the character of the pains three qualities should 
be considered: (1) their length, (2) strength, and (3) their frequency. 

Causes. The cause of deficient uterine action may be either in the 
uterus itself or in some other organ. There may be some congenital 
malformation, as the uterus bicornis, or the uterine muscle may have 
been weakened by previous inflammation, by menorrhagia, by repeated 
abortions, or by too frequent childbearing. Its fibres may be so stretched 
that they cannot contract efficiently, as in multiple gestation or hydram- 
nios. There may be malpresentation, or too early rupture of the mem- 
branes, or a faulty attachment of the placenta, as in placenta prsevia. 
Xew growths in the uterine wall, as myomata ; displacements of the 
uterus, as prolapsus ; or deviations in its axis, may all cause inertia. 
Uterine weakness in the third stage frequently occurs in precipitate labor; 
and, on the other hand, it is very likely to follow a prolonged and painful 
first and second stage. 

Very often the cause of weak uterine action must be sought elsewhere. 
A distended bladder or rectum, a dilated stomach or intestine, may so 
alter the position and axis of the uterus as to make its contractions pain- 
ful and inefficient. Sometimes the patient does not use her abdominal 
muscles properly and the uterus is unable to overcome the resistance of 
the parturient canal unaided. The physical strength of a patient is not 
always a correct index of the expulsive power of her uterus or of the 
ease of her labor; much depends upon her fortitude and pluck and the 
intelligent use of her voluntary muscles. Weak, delicate women (e. g., 
consumptives) frequently have strong pains and easy labors, while robust, 
powerful women are often disappointing by reason of their weak pains 
and tedious labors. 

Long residence in tropical climates tends to cause uterine inertia. 
European women in India suffer from menorrhagia, uterine inertia, and 
post-partum hemorrhage. A luxurious and enervating life predisposes 
to inertia. Age has also a certain influence; in young primiparse the 
pains are apt to be imperfect and irregular. Mental conditions, such as 
grief, excitement, and depression, often weaken the force of the uterine 
contractions. 

Symptoms. The symptoms depend upon the stage of labor. If the 
membranes are unruptured and weakness manifests itself during the first 
stage, the pains are short, the cervix dilates very slowly, the bag of mem- 
branes does not feel tense or press down into the cervix during a contrac- 
tion, the presenting part descends but slightly with each pain, and may 
be pushed back easily with the examining finger. If the membranes rupt- 
ure early, the presenting part advances slowly or not at all. The chief 



414 PATHOLOGY OF LABOR. 

indication, therefore, of deficient uterine action in the first stage is delay 
or arrest of labor from imperfect dilatation of the cervix. Constitutional 
svmptoms (elevation of temperature, pulse, and respiration) do not usu- 
ally appear unless the delay is very prolonged. In the second stage 
the svmptoms are chiefly those of pressure. If the presenting part is 
arrested but not impacted, the pressure symptoms may not be pronounced ; 
but if impaction occur, the vagina soon becomes hot, dry, swollen, and 
tender, the external genitals swell, and there may be cramps in the legs 
and cutting pains in the back, loins, and abdomen. After a time con- 
stitutional symptoms develop, the pulse, temperature, and respirations 
rise, the tongue becomes furred and dry, nausea and vomiting may occur, 
the countenance becomes anxious, the face swollen, the patient restless, 
and if she be not promptly relieved, low muttering delirium supervenes 
and death ensues with symptoms of profound exhaustion. It is remark- 
able with what rapidity nervous exhaustion takes place when strong 
uterine contractions are unable to overcome the resistance of the birth- 
canal. The fcetus, too, shows signs of distress ; its movements become 
violent, the foetal heart-beat increases and then rapidly decreases in fre- 
quency, and finally death occurs from asphyxia. 

Sometimes the uterine weakness is not general, but is confined to the 
fundus, the placental site, or a portion of the anterior or posterior wall. 
If the weakness is in the fundus, labor is usually slow ; if in the anterior 
or posterior wall, the weakened portion bulges, and rupture may take 
place ; if near the placental site, there may be deficient contraction and 
retraction during the third stage, and the placenta may be retained, or 
hemorrhage may occur. 

Care should be taken to distinguish between a powerless uterus and a 
tetanically contracted uterus. In both cases labor is arrested or delayed, 
but in the latter case the condition is more serious. The uterus retract- 
ing about the fcetus becomes unevenly pressed about the limbs and body 
of the child, and certain portions of its walls becoming intensely con- 
gested and thinned out may rupture or slough subsequently. The teta- 
nic uterus is known by its constantly hard and board-like feel ; such a 
condition should not be ascribed to inertia uteri. 

The effects of deficient uterine action upon the third stage of labor are 
important. The uterus may have acted well during the first and second 
stages, but may have become so exhausted that it cannot contract and 
retract satisfactorily during the third stage. Occasionally the weakness 
in the third stage is only the continuation of weakness in the first and 
second stages. Good uterine contraction is essential to the proper sepa- 
ration and expulsion of the placenta; hence when the pains are infrequent 
and weak, the placenta is apt to remain partially or wholly adherent, and 
in the former case hemorrhage occurs. After separation has taken place 
a weak uterus may be unable to expel the placenta and membranes from 
its cavity, and even after they have come away it may tend to relax and 
permit free hemorrhage or the formation of a large clot. 

Diagnosis. The diagnosis is made by making a vaginal examination 
during a pain and by palpating the abdomen externally. In the first 
stage of labor, if the bag of membranes does not become tense, and the 
presenting part does not descend during a pain, if the cervix does not 
dilate and labor does not advance, the uterine action is inefficient. If 



AXOMALIES OF THE MECHANISM. 415 

in the second stage the presenting part becomes arrested or impacted, if 
the maternal passages become dry, swollen, and tender, and especially if 
constitutional symptoms supervene, it is safe to conclude that the expel- 
laut forces are unable to overcome the resistance of the parturient canal. 
By palpating the abdomen it may be ascertained how frequent and strong 
the pains are, and whether there is any deviation in the axis of the 
uterus, or whether a distended bladder is interfering with uterine action. 
In doubtful cases the condition of the thoracic and abdominal viscera 
should be ascertained. 

Prognosis. The prognosis depends upon the stage of labor, the degree 
of weakness and its cause. In the first stage, if the membranes are 
unruptured there is usually very little danger for either mother or child; 
but if the membranes have been long ruptured the life of the foetus may 
be imperilled. In the second stage there may be danger for mother and 
child if labor be too much prolonged. According to some authorities, 
delivery cannot be delayed safely beyond seven or eight hours after rup- 
ture of the membranes. No such hard-and-fast rule can be laid down, 
since in some cases a long delay may be harmless, while in others a com- 
paratively short delay may entail serious consequences. The condition 
of the mother and child should be watched carefully in all cases of 
delayed labor. A slowing foetal heart foreshadows danger to the child, 
while local oedema and a rising pulse and temperature are maternal 
danger-signals which should not be disregarded. As a general rule, the 
longer the delay the worse is the prognosis for both mother and child. 
The prognosis is usually better in multipara? than in primiparse, and 
better in partial than in total uterine weakness. Atony of the 
placental site and general atony of the uterus in the third stage are 
serious conditions, for they may lead to violent or uncontrollable 
hemorrhage. 

Treatment. The treatment varies according to the stage of labor, the 
cause of inertia and its extent. The room should be kept cool, since 
heat favors uterine weakness. Visitors should be excluded and the 
patient kept free from excitement. If the cause of inertia can be ascer- 
tained, it should be removed if possible; a distended bladder or rectum 
should be emptied, a deflected uterine axis straightened. In the first 
stage of labor, if the membranes are unruptured and the patient is 
exhausted, no attempt should be made to excite uterine action, but rest 
and sleep should be secured by means of chloral, grs. xx, repeated if 
necessary, or a hypodermic of morphia, gr. J- to J. Chloral is generally 
preferable to morphia, because it does not arrest the progress of labor. 
Opium is apt to stop or weaken the pains, and should be used only when 
the suffering is too great to be relieved by chloral. Chloral and opium 
may be combined sometimes with advantage ; a very good draught is : 

Chloral, by drat grs xx; 

Lip. op. sed. (Battley) TiPx ; 

Syr. aurant 5ij ; 

Aq. ad Sj— M. 

Antipyrine is sometimes useful when the pain is mainly neuralgic in 
character. At the same time broth, hot milk, gruel, or some other 
nutritious assimilable food should be given to maintain the patient's 



416 PATHOLOGY OF LABOR. 

strength. After a few hours' rest strong uterine action generally sets in 
and labor proceeds normally. If the membranes have been long ruptured 
and further delay seems inadvisable or dangerous, coffee, broth, or eggnog 
may be administered, and attempts made to increase the power of ute- 
rine contractions. Quinine is sometimes of great value, but it must be 
given in large doses to be effectual — not less than fifteen grains should 
be given in two powders or cachets, within the space of half an hour. 
Strychnine hypodermically (gr. -^ to ^V) is very often useful, especially 
if the heart's action is weak. Locally, a copious hot vaginal douche 
(3 to 4 quarts of boiled water at a temperature of 105° to 110° F.) 
mav be given every hour or two. Good results have been reported 
from the introduction of a soft bougie into the uterus, as in Krause's 
method of inducing labor. On the Continent a favorite method is to 
pass a rubber bag (colpeurynter) into the vagina and then distend it 
slowly with water or air. The Champetier de Ribes bag, introduced 
into the uterus, is very useful for this purpose, and sometimes changes 
the character of the pains remarkably. Hot fomentations to the fundus 
are employed sometimes to excite or increase uterine action. 

It is the custom with some practitioners to rupture the membranes 
early in the first stages of the labor for the purpose of hastening 
delivery. Such practice is not only harmful, but actually tends to pro- 
long rather than shorten labor, especially when uterine action inclines 
to be weak. As a rule, the membranes should be preserved intact as 
long as possible, or at least until dilatation of the cervix is nearly com- 
plete. When, however, the uterus is overdistended, as in hydramnios, 
and the contractions are weakened thereby, it is advisable to rupture the 
membranes, even though the os is only partially dilated, in order that 
the tension may be relieved and uterine action stimulated. 

In the second stage, when further delay is likely to be injurious, labor 
should be terminated as soon as possible. When delay is due to weak 
muscular action, or to some deviation in the uterine axis, a change of 
posture often produces the happiest results. If there is excessive right 
obliquity the patient should be made to lie on the left side; if there is 
ante version from lax abdominal w^alls, a binder should be applied and 
the patient should lie on the back. Sometimes uterine action may be 
stimulated very satisfactorily by changing the patient from the lateral to 
the dorsal position and raising the shoulders till she is sitting almost 
upright, or by causing her to get out of bed and walk about, or stand or 
sit for a time. 

Manual pressure applied to the fundus through the abdominal wall is 
a valuable means of intensifying feeble pains and prolonging their effi- 
ciency. The patient should lie in the dorsal position, and pressure 
should be made during a pain in the axis of the brim, much in the same 
way as in the Crede method of expressing the placenta. Schmidt, of 
Moscow, places the patient in the extreme lithotomy position during this 
manipulation. Roughness should be avoided, and care should be taken 
not to compress or injure the ovaries. 

Recently the use of ergot has been warmly recommended to increase 
the force oi the pains in the second stage of labor. It is possible that 
such practice may be serviceable in exceptional cases, but ergot is more 



ANOMALIES OF THE MECHANISM. 417 

or less dangerous before the birth of the child, and its use cannot be 
recommended unless for some special indication. It should be given 
cautiously, a dose of t^x to xv of the fluid extract hourly for two or 
three hours usually being sufficient. 

Operative interference (forceps, version, etc.) may be required to ter- 
minate labor. Xo doubt much harm may be done by the rash and indis- 
criminate use of forceps; but it is possible to err in the other extreme; 
indeed, it is quite likely that more lives have been lost and more serious 
injury has been done by deferring the use of forceps too long in linger- 
ing labor than by operating too early. 

(c) Spasm and Irregularity — Rigid Os and Cervix — Tetanus 

Uteri. 

The uterine contractions may be abnormally painful, and whether 
strong or weak they may be faulty in direction, duration, or effect. 
Such spasmodic contractions may be general or partial, and although 
clonic at first, they soon tend to become tonic. The so-called tetanus 
uteri is a condition of general tonic contraction. 

Causes. A uterus rendered irritable by previous endometritis may take 
on spasmodic action after premature rupture of the membranes, especi- 
ally if there is malpresentation or impaction, or if there is undue resist- 
ance, as in pelvic deformity. The tendency to spasmodic action is 
increased by too early use of ergot, by repeated vaginal examinations, 
or by rough manipulations, as in attempts to dilate the cervix forcibly 
or to deliver by forceps or version through a partially dilated cervix. 
Iu the third stage of labor, attempts to deliver the placenta by traction 
upon the cord may cause a similar condition. When the spasmodic 
action does not involve the whole uterus the structures most commonly 
affected are the circular fibres around the external and internal os and 
the orifices of the Fallopain tubes, and then a sort of spasmodic stricture 
is produced. Stricture and tetanus uteri differ only in degree ; the 
former readily passes into the latter, followed by marked constitutional 
disturbance, if the spasm be not promptly relieved. Spasmodic con- 
traction of the internal os may delay labor ; a similar effect may be 
produced by the undue contraction of Bandl's ring (contraction-ring), 
commonly called hour-glass contraction of the uterus. 1 The disturb- 
ances in the course of labor caused by this spasmodic constriction vary 
according to the position of the foetus in utero, the degree of uterine 
activity, and the amount of constriction caused by the ring. The con- 
stricting fibres prevent the descent of the foetal parts which are above 
them into the lower uterine segment, and this holding back of the foetus 
prevents the advance of the parts which are already below the ring. As 
a result of this obstacle to descent the progress of labor is retarded or 
arrested altogether. 

Diagnosis. If the fibres of the os and cervix are chiefly involved, the 
os is sensitive to touch and feels to the examining finger like a tensely 
stretched ring ; it may remain unchanged for hours in spite of strong 

1 Some writers maintain that hour-glass contraction is caused by the spasmodic contraction 
of a band of circular fibres in the uterine body above the level of Bandl's ring. 

27 



418 PATHOLOGY OF LABOR. 

uterine action. The rigid os caused by spasmodic action is sometimes 
called the whip-cord- os ; it is usually found in nervous women. The 
cedem'atous os is caused by prolonged pressure of the hard head against an 
imperfectly dilated os. It occurs generally after too early rupture of the 
membranes. These forms of rigid os must be distinguished from the 
cartilaginous os, which is caused by an excessive amount of fibrous 
tissue in the cervix and os. This is found in women with masculine 
pelves, or with procidentia uteri, friction causing an increase of fibrous 
tissue. The lower uterine segment and the cervix may thin out and 
become stretched over the presenting part, yet the os does not yield. 
When there is general tonic spasm the uterus does not relax, but remains 
in a state of continuous contraction, and through the abdominal wall 
feels as hard as a board. If it becomes moulded about the head, elbows, 
and knees of the foetus, and assumes an irregular contour, the foetus is 
held gripped in the spasmodic clutch of the uterine fibres, and labor is 
arrested. 

Prognosis. The prognosis is more favorable for mother and child in 
stricture than in tetanus uteri. In the latter the placental circulation 
is seriously disturbed and the child is apt to perish soon from asphyxia. 
After a time the uterus becomes so unevenly thinned and stretched that 
it is likely to rupture or to be injured and lacerated during attempts to 
effect delivery. 

Treatment. Whenever spasmodic action of the uterus exists, even in 
slight degree, frequent vaginal examinations and rough manipulations 
should be avoided and ergot should not be given. In mild cases and in 
the early stages generally, spasm may be relieved by the internal admin- 
istration of chloral (gr. xx, not more than three doses being given), or by 
a hypodermic injection of morphia. Locally much relief is obtained by a 
hot sitz bath and copious hot vaginal douches. If these measures fail, chlo- 
roform should be administered at once and continued till spasm is relieved. 
Unless in cases of extreme urgency, delivery by forceps or version should 
not be attempted until the os has become well dilated and uterine spasm 
has relaxed, otherwise so much force may be required to effect delivery 
that serious injury may be done to both mother and child. If the os is 
rigid and operation is urgently demanded, manual dilatation under chlo- 
roform should be tried, or a Champetier de Ribes bag may be used ; if these 
measures fail, multiple incisions should be made in the os. When the 
child is dead, or cannot be delivered alive, embryotomy should be per- 
formed. In extreme cases Csesarean section may be required. Under 
no circumstances is it wise to resort to accouchement force in such cases. 
Under proper management, tetanus uteri should not be allowed to de- 
velop. Even after delivery has been effected all danger is not over : 
the placenta may be retained and the patient may require to be deeply 
anaesthetized before it can be extracted ; severe bruising and laceration 
may have taken place, and the patient may suffer subsequently from 
pressure-fistuke, pelvic exudations and inflammations, or from septi- 
caemia. 

Some obstetricians report considerable success in the treatment of rigid 
os with the use of cocaine and atropine. The os is painted with a 2-4 per 
cent, solution of cocaine, or a cocaine suppository is placed in the cervi- 



ANOMALIES OF THE MECHANISM. 419 

cal canal, or a hypodermic injection of atropine (gr. -£-§) is made into the 
rigid cervix. 

Some writers describe a variety of cervical spasm in which the cervix 
contracts tightly about the neck of the child after the head has passed. 
This condition, however, seems to be an elastic rather than a spasmodic 
contraction of the cervix, which continues if the shoulders are very large 
and the uterus is lacking in expulsive power. In most cases it may 
be overcome readily by stretching the contracting ring with the fingers 
while strong downward pressure is made upon the fundus. 



CHAPTER XX. 

ANOMALIES OF THE MECHANISM.— Continued. 
2. ANOMALIES OF THE PASSAGES. 

A. Hard Parts — Pelvic Deformities. 

Under this heading are included all variations from the normal type 
of bony pelvis. The great majority of these anomalies are of the nature 
of contractions, which make labor a difficult or dangerous process for 
the mother, the child, or for both, and which generally call for some form 
of artificial delivery. The pelvis may be contracted in any or all of its 
diameters, but as the most serious forms are those in which the brim is 
affected, it is very common to use the term " contracted" as referring to 
these alone. In such a sense it is employed in this chapter, unless other- 
wise indicated. 

Contracted pelves may influence the position of the uterus during 
pregnancy. Thus, in the early months marked contraction of the pelvic 
inlet may cause the growing organ to become retro verted, a condition 
which may be followed by incarceration in the pelvis. In the late 
months the uterus is higher than normal, the foetal head not being able 
to sink within the pelvic cavity. The abdomen is rendered unduly prom- 
inent ; pendulous belly is often marked; the long axis of the uterus being 
directed forward or to one or the other side. 

Contracted pelves also influence the presentation and position of the 
foetus, malpresentations and malpositions being about three times as fre- 
quent as in normal pelves. Thus a vertex presentation may be changed 
to a brow, face, or transverse. When the breech presents the knees or 
feet are apt to descend. The cord is also apt to prolapse into the lower 
pole of the uterus. These malconditions are favored by multiparity, 
owing to the increased relaxation of the uterine and abdominal walls. 

But it is in labor that the most marked effects of contracted pelves 
are seen. At the beginning of the first stage the presenting part is 
higher than in the normal condition, and it does not fit well into the lower 
pole of the uterus. The cervix and lower uterine segment hang loosely 
at or above the brim. The liquor amnii is driven downward, and there 
is a tendency to the protrusion of the bag of membranes through the 
slowly dilating cervix as a sausage-shaped mass. Frequently the bag 
ruptures early, the uterus being drained of the liquor amnii. If the 
contraction be not too great to allow the foetus to be born, labor may 
continue, being prolonged and painful, the cervix dilating slowly, and 
the foetus born dead, the head being much altered by moulding, some- 
times with fractures of its bones. If the labor be too prolonged in such 
a case, or if the contraction be too great to allow T the foetus to descend at 
all, the mother may become completely exhausted, and labor may cease 
for a time, or excessive thinning and stretching of the lower uterine 
segment may continue until it ruptures, alone or along with the cervix 
and vaginal wall; sometimes the uterus may be torn from the vagina. 

( 420 ) 



AXOMALIES OF THE PASSAGES. 421 

In any case there is apt to be bruising of the soft parts from prolonged 
pressure of the head, and this may be followed by sloughing. 

It is thus evident that the risks to the mother are varied and serious. 
The life of the foetus is also greatly endangered, owing to pressure on 
the head, prolapse of the cord, delay in delivery, or to complications 
arising from operative measures necessary to the extraction of the 
foetus. 

Frequency. Deformed pelves are generally considered to be much 
more frequent in the Old World than in the New. In the light of 
recent work it is doubtful if this widely held view is correct. In both 
continents it is very difficult to get accurate data regarding the frequency 
of their occurrence. This is due to the fact that there is an absence of 
a common understanding regarding the definition of deformity. Thus, 
both in Europe and America, many observers have neglected minor 
degrees of contraction, considering only those capable of causing serious 
troubles. Statistics vary also according to the expertness or fitness of 
different observers in recognizing deformities. 

In this connection the recent work of Williams and Dobbin, of Johns 
Hopkins, is worthy of the most careful study. Their observations are 
a direct challenge to those who hold the common belief regarding the 
infrequency of pelvic deformity in America. It is their view that defor- 
mities are considered rare only because they are not systematically looked 
for by the routine examination and measurement of all pregnant and 
parturient women. In 1000 cases of labor observed by them there were 
131 contracted pelves, or 13.10 per cent. Of this number, 46, or 35.11 
per cent., were of such a degree as to necessitate operative delivery. It 
is interesting to compare these figures with those of Winckel, who states 
that 10 to 15 per cent, of all childbearing German women have con- 
tracted pelves, but that only in 5 per cent, is the contraction serious 
enough to be noticed. The percentage of operative frequency in Europe 
is variously noted by different workers. Knapp puts it at 61 per cent. ; 
Heinsius, 56.84 per cent. ; Ludwig and Savor, 45.6 per cent. ; Bos- 
mann, 24.5 per cent. ; Franke, 20.5 per cent. In America the largest 
percentage is that of Flint, of New York, viz., 46. The well-known 
statistics of Reynolds, of Boston, are not at all reliable with regard to 
the frequency of all degrees of pelvic deformity, for, of the 2127 cases 
studied by him, measurements were made practically only in those in 
whom operative delivery was carried out. 

Williams and Dobbin have shown that such a method of inquiry can 
result only in the non-recognition of a considerable number of deform- 
ities. This was demonstrated by their careful study of negro women. 
They found that pelvic contractions were much more frequent among 
these than among white women. Yet, on account of the small and 
easily moulded foetal head, the degree of contraction is rarely sufficient 
to obstruct labor to a serious degree. Therefore, if only those cases 
were considered in which operative interference is necessary, a consider- 
able number of deviations from the normal would be overlooked. 

The most frequent contractions met with in practice are the fol- 
lowing : 

1 . The justo-minor or universally contracted pelvis. 

2. The flat non-rickety and rickety. 



422 PATHOLOGY OF LABOR. 

3. The funnel-shaped pelvis. 

4. The pelvis altered by various spinal deformities. 

Of these, perhaps the most common are the universally contracted 
and the flat. 

Diagnosis of Anomalies of the Hard Pelvis in General. Three lines of 
investigation open to the obstetrician for determining the condition of a 
woman' s pelvis : 

1. A careful study of the history of her previous health and labors, 
and a thorough examination of her physical condition; 

2. The study of the mechanism of labor itself; 

3. Evidence may be gained from the condition of the child's head 
after delivery. 

The latter two subjects will be considered with the individual pelves. 
In this section attention will be directed alone to the first heading. 

In examining a woman her previous history should be inquired into. 
If she had suffered from rickets in childhood there would be a history 
of late dentition, irritability, bad digestion, restlessness and perspiration 
at night, late closure of the anterior fontanelle. She may have had bend- 
ing of the long bones or spine, square head, pigeon-breast, rosary ribs, 
enlarged ends of long bones, and she may be of short stature. 

Various deformities of the pelvis may be associated with rickets — 
e. g., the rachitic generally contracted, the rachitic infantile, the rachitic 
flat, the scolio -rachitic, the kypho-scolio-rachitic, and the rachitic rostrate 
( pseudo-malacosteon rachitic). 

The patient may have suffered from osteomalacia, in which case she 
would probably give a history of poverty, overwork, and exposure to 
cold and wet under unfavorable conditions of life, the disease having 
begun in a former pregnancy or lactation-period, with dull or aching 
pains in the limbs, back, and pelvis, worse on movement. 

Tuberculosis may have affected her in one or other lower extremity, 
in the hip, or sacro-iliac joint, leading to a simple oblique contraction of 
the pelvis ; or it may have occurred in the spine, giving rise to kyphosis, 
which secondarily may affect the pelvis. 

The patient may have suffered from accident to a limb, resulting in 
shortening, dislocation, weakening, or amputation, secondarily leading to 
a single oblique contraction of the pelvis ; or injury may have dislocated 
the lumbar vertebrae from the sacrum, causing the condition of spondy- 
lolisthesis. 

Possibly the patient may give a history of a weakly early life, asso- 
ciated, however, with no special disease. Such a condition may be 
associated with a flattening of the pelvis or with some maldevelopment. 
Or she may have been born with a congenital dislocation of one or both 
hips, or with spondylolisthesis. 

But the most satisfactory information is derived from the physical 
examination of the pelvis — pelvimetry. A series of measurements are 
to be made in the following systematic manner. 

(a.) External Measurements. 

1. Antero-posterior. An important antero-posterior measurement is 
that known as the "External Conjugate of BaudelocqueP To determine 
this, the patient is placed on her side, her hips being carefully exposed 



AX03IALIES OF THE PASSAGES. 423 

and the clothes tucked out of the way. The physician stands behind 
the patient, looking toward her head. He then takes a pair of calipers, 
the so-called pelvimeter, and holds a rod in each hand, the tip of the 
index-finger being on each knob. The knob of one rod is placed in the 
depression just below the spine of the last lumbar vertebra, and the other 
on the skin of the mons veneris in front of the upper part of the sym- 
physis. The rods are then fixed in position, a screw being turned by 
an assistant, and the measurement is read on the scale attached to the 
instrument. 

To determine the length of the conjugata vera, it is necessary to sub- 
tract that which represents bones and soft tissues. This varies greatly in 
different cases and cannot be accurately determined. In 30 cases in 
which Litzmann measured the external conjugate during life and 
the true conjugate after death there was an average difference between 
the two of 9.5 cm. (3|- in.) ; in the whole series there was a range from 
7 cm. [2^ in.) to 12.5 cm. (4||- in.). In some cases the conjugate of 

Fig. 251. 




Baudelocque's pelvimeter, 

Baudelocque indicates contraction of the pelvis with certainty ; in others, 
non-contraction with equal certainty. There are, however, many cases 
in which it cannot be relied on. Jewett states that with an external 
conjugate at or below 6 in. (15.2 cm.), or even below 6} in. (15.8 cm.), 
the pelvis is invariably contracted ; at or above 8 in. (20.3 cm.) the 
pelvis is almost surely ample ; between 6^ and 8 in. the length of the 
vera is doubtful, and must be settled by other measurements. 

There is another manner in which the vera may sometimes be made 
out in a thin non-pregnant woman, or in a pregnant woman whose uterus 
has not risen above the brim, viz., by placing the hand on the hypo- 
gastrium and pressing the abdominal wall with the tips of the straight- 



424 



PATHOLOGY OF LABOR. 



enecl fingers against the promontory ; the thickness of the abdominal 
wall and pubes can be fairly correctly estimated and allowed for. 

2. Transverse. It is impossible to estimate the transverse diameter of 
the true pelvis accurately. The following measurements are usually 
made : 

(«) Interspinous ; between the anterior superior iliac spines. In 
normal cases this varies from 9h to 10J in. (24.1 to 26.7 cm.). 

(b) Intercristal ; between the widest parts of the iliac crests. In 
normal cases this varies from 10^- to 11^- in. (26.7 to 29.1 cm.). 

In the normal pelvis the average difference between (a) and (b) is 
1 in. 

(c) Between the posterior superior iliac spines. This measures nor- 
mally about o^ in. (9.8 cm.). 

(d) Between the great trochanters. This measurement is not very 
reliable, owing to variations in the head, neck, and trochanter of the 
femur. If, however, it be less than 11J inches, transverse contraction 
of the pelvis may be suspected. 

If all of these measurements are considerably less than the normal, 
transverse contraction of the pelvis is certain. 

3. Oblique. The measurements made for the purpose of determining 
oblique contractions of the pelvis are given on page 438. 



Fig. 252. 




Measuring the conjugate in a non-pregnant rachitic woman by external application of the hands. 



(b.) Internal Measurements. 

For the purpose of determining the size of the pelvic canal the fingers 
alone are sufficient. 

By a careful vaginal examination the wall of the canal may be pretty 
thoroughly examined. A good general idea of the capacity of the canal 
may be made out, projections can be felt, anchylosis of the coccyx can be 
determined, and the size of the outlet estimated. The height of the 
symphysis can also be made out. Certain special measurements must, 
however, be made : 

1. The diagonal conjugate — i. e., from the promontory to the subpubic 
ligament. In determining this the patient should be placed in the lith- 
otomy position, aud the first two fingers, extended, should be passed up 
the vagina until the tip of the second finger touches the promontory. 



ANOMALIES OF THE PASSAGES. 425 

The radial side of the hand is then raised until it presses against the sub- 
pubic ligament, and a mark is made at this point on the hand, which is 
then withdrawn. With a pelvimeter the distance between this mark and 
the tip of the second finger is then taken. This is the length of the 
diagonal conjugate. In the normal pelvis it is J to f inch greater than 
the trne conjugate of the brim. The difference between these diameters 
varies in different pelves, according to the height of the symphysis, the 
height of the promontory, and the angle between the vertical axis of the 
symphysis and the true conjugate. 

Thus, in the rickety flat pelvis, where the height of the symphysis is 
greater than normal, and the angle between its axis and the vera is also 
greater, the difference between the diameters is greater than in the normal 
pelvis. 

"When the height of the symphysis is more than 1^- in., slightly 
more than f in. should be deducted from the diagonal conjugate. 

In the great majority of cases a diagonal conjugate of less than 4^ in. 
(11.5 cm.) indicates antero-posterior pelvic contraction. 

2. Lohlein's measurement, from the subpubic ligament to the upper 
anterior angle of the great sacro-sciatic notch. This is said to be 
normally f in. (2 cm.) less than the transverse diameter of the 
brim. 

3. Hirst's measurements, from the promontory to the upper outer edge 
of the symphysis. This is taken with a special pelvimeter consisting of 

Fig. 253. 




Internal pelvimetry. Measuring the diagonal conjugate with the hands. 

a long straight rod which is passed up the vagina to touch the promon- 
tory, and a short curved rod, which touches the front of the symphysis. 
When the instrument is in position its rods are tightened and then 
removed, the distance between the points of the rods being measured. 
The thickness of the upper parts of the symphysis is then measured 
with a small pair of calipers and is subtracted from the first obtained 
length, in order to give the length of the true conjugate. 

In measuring the diagonal conjugate with the fingers, there may be 
difficulty in reaching the promontory if the patient strains much, if the 
perineum is rigid, if the pelvis is very deep, or the promontory high or 



426 PATHOLOGY OF LABOR. 

far back. The condition of double promontory, viz., that in which the 
junction of the first and second sacral vertebrae projects forward, like 
that between the last lumbar and first sacral, may exist and lead to an 
error in estimation; the point nearest the symphysis should always be 
chosen. In these conditions of difficulty the employment of general 
anaesthesia is of great value. 

It is of great importance, also, to measure the conjugate and transverse 
diameters of the outlet. For this purpose special instruments are em- 
ployed by some, but exact information can be obtained with the fingers 
and calipers. 

Careful routine pelvimetry should be carried out by all who practise 
obstetrics. In this way alone it is possible to work with scientific accu- 
racy and to avoid those risks to mother and child which are certain to 
attend him who establishes a diagnosis after the complications of a dys- 
tocic labor have begun. 

Classification. 

Various classifications are employed in different countries. It is need- 
less for the student to study the relative merits of these. It is best to 
select one as his basis of study, realizing that no system can satisfy all 
requirements of scientific completeness. The following plan is recom- 
mended : 

I. Pelves normally proportioned but abnormal in size: 

1. Uniformly enlarged (cequabiliter justo -major). 

2. Uniformly contracted {cequabiliter justo-minor), 

II. Pelves with anomalies of size, shape, inclination, or combinations 
of these : 

1. Those with minor developmental peculiarities : (a) Masculine 

(b) shallow, (c) deep, (d) funnel-shaped. 

2. Antero-posteriorly contracted: 
Flat, non -rachitic. 

Flat, rachitic. 

3. Obliquely contracted: 

By imperfect development of one sacral ala (Naegele pelvis). 
By imperfect or abolished use of one limb. 
By lateral spinal curvature. 

4. Transversely contracted: 

By imperfect development of both sacral alae (Robert pelvis). 
By kyphosis of the spine. 

5. Compressed pelvis: 
Malacosteon. 

Pseud o-malacosteon rachitic. 

6. Spondylolisthetic. 

7. Pelvis distorted by injury, tumors, anchylosis of joints. 

8. Deformity due to spinal curvature : 
(a) Kyphotic. 

(6) Scoliotic. 

(c) Kyphoscoliotic. 

(d) Lordosis. 



AX03IALIES OF THE PASSAGES. 



427 



Fig. 254. 



Individual Forms. 
I. Pelves Normally Proportioned, but Abnormal in Size. 

Uniformly Enlarged Pelvis (cequabiliter justo-major). This pelvis has 
all the characters of a normal pelvis, except that all the measurements 
are proportionately increased in size. They are found in large, though 
not necessarily in tall, women. 

Influence on Pregnancy and Labor. In pregnancy the uterus 
tends to remain longer in the pelvis than in a normal condition, and, 
consequently, to disturb the bladder and rectal functions. It is gener- 
ally believed that the labor is apt to be a hur- 
ried one. There is a greater tendency to post- 
partum hemorrhage, as Webster has shown, 
owing to the imperfect filling of the pelvis by 
the uterus. 

Uniformly Contracted Pelvis (cequabiliter justo- 
minor). The most common form has the cha- 
racters of a normal female pelvis save that all 
the measurements are proportionately dimin- 
ished. It is found in women slightly under- 
sized, but may also occur in persons of ordinary 
height, or even in tall women. 

Two other varieties are described by many 
authors, viz., the infantile form, in which, with 
the small size of the bones, many of the fea- 
tures of the early pelvis are retained, and the 
dwarf form, in which the bones are slender and fragile, the cartilaginous 
junctions between the constituents of the ossa innominata being retained. 




Diagram showing head un- 
moulded and moulded by labor 
in normal vertex case. 

Black, unmoulded. 

Red, moulded. 



Fig. 255. 




Generally contracted dwarf pelvis. (After Winckel.) 



Etiology. The causation of this condition is .not well known. In 
some cases it is due to imperfect development — (-'•[/., in dwarfs. In 



428 



PATHOLOGY OF LABOR. 



other cases it may be due to unfavorable hygienic surroundings and bad 
nutrition in early life. 

Diagnosis. The diagnosis is based on careful pelvimetry. The justo- 
miDor pelvis may easily be mistaken for a rachitic pelvis. 



Fig. 256. 








Diagram showing difference between normal and justo-minor pelvis on vertical mesial section. 
Black, normal. Red, justo-minor. 

Influence on Labor. If the contraction is not too great to allow 
the foetus to be born, the labor takes place by a definite mechanism which 

Fig." 257. 




Infantile pelvis. (After Ahlfield.) 



resembles that in a normal pelvis, the flexion, however, being much more 
marked. In the normal pelvis flexion occurs so that the suboccipito- 
bregmatic diameter, drawn to the anterior angle of the bregma, comes 



AS OM A LIES OF THE PASSAGES. 



429 



Fig. 258. 




Diagram showing out- 
line of brim of normal 
and of justo-minor pelvis. 

Black, normal. 

Red, justo-minor pelvis. 



Fig. 259. 



into relation with the brim. In the justo-minor pelvis a shorter posterior 

suboccipito-bregmatic diameter comes into relation 

with the brim as a result of the increased flexion, 

depending upon the increased resistance with which 

the head meets. On examination, during labor, 

the tip of the occiput or even the external occipital 

protuberance (inion) may be felt in the centre of 

the canal. 

After flexion, internal rotation, extension, and 
external rotation occur as normally. 

The labor may be much prolonged. Sometimes 
the pains may cease for a time, owing to the great 
resistance, or to the paralyzing effects due to the 
pressure on the soft parts between the foetal head 
and the bony pelvis. 

Head Moulding. The head is markedly compressed in the sub- 
occipito-bregmatic diameter and elongated in the occipito-mental. In 
profile it has the shape of a sugar-loaf. This is 
all the more marked if a large caput succeda- 
neura has formed over the tip of the occiput. 

Treatment. When the labor is delayed 
in a justo-minor pelvis forceps should be 
tried, provided the canal is large enough. 
This method may be employed when the brim 
conjugate is as low as 9.5 cm. (3f in.). 

The forceps is used because it assists the 
natural mechanism — i. e., it allows the head to 
be well fixed. Walcher's position and the em- 
ployment of axis-traction forceps make it possi- 
ble to deliver a normal head through a brim 
whose conjugata vera measures 8.4 cm. (3 \ in.). 

Symphyseotomy may be recommended as 
an adjuvant to the above-mentioned method 
when the conjugata vera measures 7.6 to 8.4 
cm. (3 to 3J in.). 

Turning must not be employed, because the head becomes extended 
thereby, and the arms are apt to be displaced upward, greatly increasing 
the difficulty of a safe delivery of the head through the brim. 




Diagram showing head un- 
moulded and moulded by labor 
in a justo-minor case. 

Black, unmoulded. 

Red, moulded. 



II. Pelves with Anomalies of Size, Shape, Inclination, or 
Combinations of These. 



1. Those with Minor Developmental Peculiarities. 

(a) Masculine. Sometimes a woman' s pelvis may present all the char- 
acteristics of a male pelvis. 

Delay may be caused in labor either at the brim or outlet. Forceps 
may be required. 

(6) Shallow. This term is applied to a pelvis in which the distance 
from the brim to the outlet is relatively less than in the normal pelvis. 

Labor is not necessarily always easy in this form of pelvis. In the 



430 PATHOLOGY OF LABOR. 

high forceps operation, however, there is less difficulty than in the case 
of a deep pelvis. 

(c) Deep. In this pelvis there is an abuormal increase in the distance 
from the inlet to the outlet. 

(d) Funnel-shaped. This term is applied to a pelvis in which there is a 
contraction of the pelvis at the outlet antero-posteriorly, transversely, or 
in both these directions. The caual, in fact, resembles that in the male 
pelvis, and by some authors "inale" and " funnel-shaped "■ are used 
synonymously. 

It must be remembered, however, that a pelvis may be funnel-shaped 
without possessing any other male characteristics. 

Diagnosis. The nature of the pelvis is made out by a careful com- 
parison of the outlet and inlet measurements and by a careful examina- 
tion of the pelvic canal. 

Fig. 260. 




Funnel-shaped pelvis. (After Winck el.) 

Influence on Labor. The mechanism of labor may be interfered 
with — i. e., flexion may be interrupted, or backward rotation of the 
occiput may occur. The labor is prolonged. The soft parts are unduly 
pressed against the bony wall — e. g., the cervix against the promontory, 
or the bladder against the pubes, and laceration or necrosis may result. 
There is greater risk of rupture of the perineum. 

Treatment. In the lesser degrees of contraction forceps should be 
used when there is delay. In more marked contractions, embryulcia, 
symphyseotomy, or Cesarean section may be required. 

2. Antero-posteriorly Contracted, or Flat Pelves. 

In these the characteristic feature is shortening of the conjugate of the 
brim. 

(a) Flat Non-rachitic, or Simple Flat. This is a common variety in 
Europe, but rare in America. There is an approach of the whole sacrum 
to the pubes, the transverse diameter of the pelvis being, consequently, 
relatively increased. The conjugate in this form is rarely below three 
inches. 

Etiology. The causes are not clearly known. Hard work in youth, 
a weakly condition of body, too early walking, lifting heavy weights, 
and excessive standing on the feet are believed to be important factors 
in causing the deformity. Sometimes the condition is congenital. 



AX01IAL1ES OF THE PASSAGES. 



431 



Diagnosis. There niay be nothing diagnostic in the build of the 
individual. It may be found in large and small women. The relation- 
ship between the intercristal and interspinous diameters may be scarcely 



Fig. 26L 




Fig. 262. 



Flat non-rachitic pelvis. (After Kleinwachter.) 

altered from the normal, or not at all. There are no signs of rickets. 
The diagnosis is based upon the shortening of the external and diagonal 
conjugates. 

(6) Flat rachitic. This is the most important form of flat pelvis. The 
following description may be regarded as that of a typical specimen. 

In general, the pelvis is heavier than a normal 
one of corresponding size, owing to the increased 
condensation in the bones as a result of the dis- 
ease. The bones are thicker, firmer, and some- 
what smaller. The sacrum, however, is wider than 
normal. 

The iliac crests do not possess the normal curve. 
They tend to become more or less everted at their 
anterior ends, so that the interspinous diameter 
approaches, equals, or is greater than the intercris- 
tal. The direction of the crests is partly due to 
the arrest of development, as the normal curve of 
the crests only appears after the age at which rickets 
occurs. The ilia are partly flattened also by the dragging of the sacro- 
iliac ligaments and the sartorii and glutei muscles. The iliac fossa? 
are not as distinctly hollowed, nor the iliac wings as expanded as in the 
normal pelvis; the fossae look more directly forward. The wings are 
more stumpy than normal. 

The brim is kidney-shaped, not heart-shaped, as in the normal pelvis. 




Diagram showing outline 
of brim of normal and 
Naegele pelvis. 

Black, normal. 

Red, Naegele. 



432 



PATHOLOGY OF LABOR. 



Fig. 263. 



The conjugate, vera is less than the normal four inches, and the trans- 
verse is both relatively and absolutely increased. 

The cavity of the pelvis is roomy and wider than in the normal state. 
The anterior surface of the sacrum is not concave from side to side, as 
in the normal condition, but, owing to the bulging forward of the bodies, 
it is either flat or convex. 

The outlet has a widened transverse; the conjugate is normal or 
slightly increased. 

The pubic arch is wide and the acetabula are directed more forward 
than in the normal state. 

On vertical mesial section the symphysis is seen to be deeper than 
normal, its long axis not being parallel with that of the upper part of 

the sacrum, as in the normal condition, but 
tending to converge toward it above the 
brim. The main extent of the sacram is 
straight from above downward. Usually a 
sharp bend occurs about the fourth vertebra. 
The relation of the conjugate, vera to the 
conjugate diagonalis is not the same as in 
the normal pelvis. In the latter the differ- 
ence between them is about half an inch. In 
the rickety the difference is greater, three- 
quarters of an inch or more, owing to two 
factors, viz., the increased depth of the sym- 
physis and the divergence of the lower 
margin of the symphysis from the normal 
position. 

Etiology. It is evident that these 
changes may be grouped around one main 
feature — the sinking of the promontory. 
Hickets causes in the early stages a soften- 
ing of the bones, and if, in this condition, 
the body be kept to a considerable extent in 
the erect or sitting posture, its weight will tend to push the promontory 
downward and forward. The lower part of the sacrum, with the coccyx, 
tends to move upward and backward, but it cannot do so to any appre- 
ciable extent, on account of being held by the strong ligaments attached 
to it. Consequently, a sharp bend is produced about the fourth sacral 
vertebra. In addition to the weight of the body, the action of the mus- 
cles attached to the pelvis may help to bring about the deformity. . The 
separation of the ischial tuberosities is due to the widening of the pelvis 
and to the action of the adductor and rotator muscles of the thigh. 
This will be increased by the weight of the body acting in the sitting 
posture. 

Rickets usually develops in the early years of life. It may occur in 
utero, and the foetus may be born with the pelvis somewhat altered; in 
the latter case probably the alterations are brought about by muscular 
action mainly. Great variations are produced by rickets, depending 
upon the date of its appearance, its severity, the habits of the child, etc. 
AYe have described the typical flat rickety pelvis. In some cases, where 
there is such a degree of disease as to permanently interfere with bone- 




Diagram showing difference be- 
tween normal and rachitic pelvis on 
vertical mesial section. 

Black, normal. Red, rachitic. 



ANOMALIES OF THE PASSAGES. 



433 



development, a condition of pelvis known as the rachitic generally con- 
tracted pelvis may be induced; or a rachitic infantile pelvis may result, in 
which there is a narrow transverse diameter, relatively to the conjugate. 
Sometimes the pubes may be bent inward toward the promontory by 
muscular action, causing the brim to have & figure-of-eight shape. When 
the disease begins after the child has learned to walk and run, the weight 
of the body is transmitted to the legs, and, owing to counter-pressure at 
the acetabula, they may be forced inward, thus giving rise to the rachitic 
rostrate, or pseud o-malacosteon pelvis. 

When lateral curvature of the spine is present as a result of the rick- 
ets, the scolio-?*achitic obliquely contracted pelvis is the result. 

Diagnosis. The diagnosis of a rachitic pelvis is formed from study- 
ing the woman's history, by her appearance, by examination and meas- 
urement of her pelvis. A woman who 
has suffered from the disease in childhood FlG - 264 - 

is usually undersized, with square head, 



flat nose, pigeon-breast, and with curved 
long bones whose ends are enlarged. 
When she lies on a flat surface, lumbar 
lordosis may be well marked. 

By the pelvimeter the normal relation- 
ship between the interspiuous and inter- 
cristal diameters is found to be altered, 
as already indicated. The external con- 
jugate of Baudelocque is less than normal. 
The diagonal conjugate is less. The dif- 
ference between the diagonal and true 
conjugates is greater than in the normal 
pelvis. 

Sometimes a condition of double prom- 
ontory exists, owing to the prominence 
of the junction of the first and second 
sacral vertebra?. In such a case the con- 
jugates should be measured from the pro- 
jection nearest the symphysis. Some- 
times, on account of marked lordosis, the 
lumbar vertebra? may be nearer the sym- 
physis than the real promontory; in this 
case the conjugates should be measured 
from the bony point nearest the symphysis. 

Influence on Pregnancy and La- 
bor. This has already been described 
(vide p. 413). 

Mechanism of Labor in a Flat 
Rachitic Pelvis. Where the foetus can be born, the passage of the 
head through the contracted brim takes place by a distinct and special 
mechanism. 

In the normal pelvis the long diameter of the head lies at the begin- 
ning of labor, as Solayres first showed, in an oblique diameter of the 
brim. In the rachitic pelvis it lies in the transverse. In the normal 
pelvis the head is flexed; in the rachitic it becomes extended — i. e., the 

28 




Pregnancy in a woman with a flat 
rachitic pelvis. The condition of pen- 
dulous belly is shown. 



434 PA THOL OGY OF LAB OR. 

sincipital end is lowered. In the normal pelvis the sagittal suture passes 
through the central point of the inlet; in the rickety pelvis, as Naegele 
first showed, the suture is nearer the posterior wall, or, in other words, 
the occipitofrontal plane of the head is oblique to the plane of the brim. 

As the second stage of labor proceeds extension of the head increases, 
the sinciput dipping, the occipital end of the head being well against the 
side of the brim, the short, bitemporal diameter being in relation to 
the conjugata vera. 

At the same time a movement takes place, known as the " rounding 
of the promontory." The head turns on its antero-posterior axis, so 
that the sagittal suture, instead of being near the promontory, approaches 
the symphysis; it then turns back again, so that the suture is nearer the 
back wall, now, however, being below the promontory. The head has, 
as it were, dodged round the promontory. 

After the passage of the brim there is no obstruction in the true pelvis, 
and the rest of the mechanism may go on normally. Or, owing to the 
width of the transverse diameter of the outlet, the head may be forced 
onward without any special mechanism. 

It is evident that should the head stick before it has passed the brim, 
different presentations may be made out clinically. Thus, a brow or 
face presentation may be found. One parietal bone may present, the 
sagittal suture being near the promontory, or the other parietal bone may 
present, the sagittal suture being near the symphysis. 

Sometimes an altogether different mechanism may be attempted — i. e., 
the head may attempt to get through one-half of the brim by a mechan- 
ism of extreme flexion. This mechanism may also be found in some 
cases of the generally contracted rachitic pelvis. 

Fig. 265. 




Depression of temporal region of skull as a result of delivery through a flat pelvis. 
(After E. Martin.) 

Head Moulding. The characteristic feature is the presence of the 
" promontory mark" — i. e., a depression in the parietal region which 
is in contact with the promontory during the passage of the brim. 
There is also generally a red mark on the skin, running from this depres- 
sion toward the temple parallel with the coronal suture. Usually the 
parietal bone which was anterior in the pelvis overlaps the other. 

Breech Delivery in a Flat Pelvis. The delivery of the trunk 



ANOMALIES OF THE PASSAGES. 435 

usually proceeds normally. The arms are more apt to be extended 
upward than in a normal pelvis. The after-coming head enters the brim 
in the transverse diameter. If the brim contraction is slight the head 
may pass through flexed; if great it becomes extended. Often it tends 
to stick above the brim. 

Treatment. For a long period the classical method of treating a 
case in which the head presents has been that of version, providing the 
conditions are favorable. Recently, however, the use of the axis-traction 
forceps has been strongly advocated, mainly by Milne Murray, who 
claims that this method is as favorable to the child as version, and no 
more dangerous to the mother. 

In a series of experiments Murray has shown that the diminution of 
the head in the occipito-frontal diameter is accompanied by a compen- 
satory bulging, not in the transverse, but in the vertical diameter, and 
that, therefore, a serious objection to the use of the forceps is removed. 
By a simple and ingenious modification of the axis-traction forceps he 
has made it possible in these cases to make the line of traction coincide 
more accurately with the altered axis of the inlet than is possible with 
the ordinary axis-traction forceps. He and others have reported a num- 
ber of cases in which his method has been successful in delivering a 
living child where marked contraction of the inlet existed. At the 
meeting of the British Medical Association in 1896 he mentioned one 
instance in which he had been successful where the brim conjugate 
measured 2.75 inches. 

Comparing the relative merits of both methods in flat pelves, it may 
be stated against version (1) that it introduces the risks connected with 
breech deliveries, e. g., asphyxiation of the foetus from pressure on the 
cord, extension upward of head or upper extremities, injury to neck, etc. ; 
(2) that it is impossible to bring down the child in the proper axis of 
the pelvis after version ; (3) that turning becomes impossible or danger- 
ous after the membranes have been for some time ruptured. 

In favor of the forceps it may be said (1) that the foetus is not ex- 
posed to the risks connected with head-last delivery ; (2) that the 
manipulative risks are not so great as in version ; (3) that forceps can he 
applied long after dilatation of the cervix and rupture of the bag of mem- 
branes ; (4) that the foetus may be withdrawn more nearly in the pelvic 
axis ; (5) that in the widened transverse diameter of the brim the blades 
of the forceps may usually be applied to the head without great diffi- 
culty ; (6) that the grip of the head, just sufficient to prevent slipping, 
does not dangerously compress the head ; (7) that the compression 
produced causes a compensatory vertical, and not an antero-posterior 
bulging. 

Of great assistance in these cases is the employment of Walcher's posi- 
tion. (See Plate XVIII.) The patient lies across the bed so that her lower 
limbs hang over the edge, the feet not touching the floor. The weight 
of the legs draws the symphysis downward, thus increasing the conju- 
gate of the inlet and correspondiugly diminishing that of the outlet. 
As much as one-third of an inch increase in the brim conjugate may be 
gained. 

A head may be drawn through the brim in this position when it is 
impossible to do so in the left lateral or lithotomy position. It is reeom- 



436 



PATHOLOGY OF LABOR. 



mended that when the head reaches the outlet the legs should be raised 
to make the conjugate of the outlet as long as possible; but as soon as 



Fig. 266. 



Fig. 26: 





Moulding of head during passage through flat 
rachitic pelvis. 



Diagram showing outline of brim of normal 
and of flat rachitic pelvis. 
Black, normal. Red, flat. 



the head has mainly passed the sacrum the limbs should be again placed 
in the Walcher position in order to relax the perineum. The raising of 
the legs is, however, unnecessary; the transverse is usually very wide in 
these cases, and the conjugate not diminished. There will, therefore, be 
little gain, even if the conjugate of the outlet be slightly increased. 

Where delivery is impossible by these methods, embryulcia or Cesa- 
rean section have been employed, depending upon the degree of contrac- 



Fig. 268. 




Siugly obliquely contracted pelvis. (After Hecker 



tion. By many, premature labor has been induced in these cases in the 
hope of getting a living child with safety to the mother. 

Recently the success of symphyseotomy has led to a very extensive 
abandonment of these latter methods, and there is no doubt that this 
operation will occupy a prominent place in the future. It should be 
employed when the child is alive, when axis-traction forceps delivery in 
the Walcher position is impossible, and when there is no doubt that the 
increased pelvic measurements resulting from the operation will allow 
the head to be extracted. Most authorities limit symphyseotomy in flat 
pelves to those cases in which the conjugata vera measures from 2.6 to 
3.2 inches. It is evident, however, that the employment of the axis- 
traction forceps in the Wak-her position must make unnecessary, in a 



AXOMALIES OF THE PASSAGES. 



437 



considerable proportion of cases, the cutting operation. It is also 
clear that symphyseotomy at full time must greatly diminish the neces- 
sity for inducing premature labor in cases of pelvic deformity. For 
a living child delivery at term by the axis-traction forceps with the 
aid of a symphyseotomy is preferable to a premature delivery with 
its risks and the uncertainty with regard to the rearing of a weakly 
child. 

The delivery of the after-coming head in breech cases is best effected 
with axis-traction forceps. 



3. Obliquely Contracted Pelves. 

(a) Resulting from Imperfect Development of One Sacral Ala (Naegele 
Pelvis). This pelvis varies somewhat in appearance, according to whether 
part or whole of the sacral ala is wanting. In a well-marked condition 



Fig. 269. 




S= -«s--— 



Singly obliquely contracted pelvis. (After Winckel.) 

the characteristic feature is the single oblique contraction of the brim. 
The latter is of somewhat ovoid shape, the small end of the ovoid 
being at the sacro-iliac joint on the diseased side. The short oblique 
diameter is that of the healthy side — i. e., if the left sacral ala is want- 
ing, the shortened oblique diameter of the brim is the right. 

The sacrum is narrowed, the sacral wing on one side being partly or 
wholly wanting. Often the sacro-iliac joint on that side is anchylosed. 
The front of the sacrum and the promontory are turned somewhat to the 



438 PATHOLOGY OF LABOR. 

diseased side. The os innominatum on this side is pushed upward, 
inward, and backward as a whole. The ischial tuberosity on this side 
is higher than that on the other, the ischial spine being closer to the 
sacrum and projecting more prominently into the pelvic cavity. The 
ilio-pectineal line is often less curved than on the healthy side. The 
subpubic angle is asymmetrical and looks toward the diseased side. The 
acetabulum on the diseased side looks almost directly outward. 

Etiology. The deficiency in the sacral ala is due either to non- 
development or to some diseased state — e. g., inflammation in early life. 
It may, therefore, be a congenital condition. 

The distortion is aggravated when the child begins to walk, and it is 
easy to understand how the displacement of the os innominatum on the 
diseased side may be brought about. It is important to note that anchy- 
losis of the sacro-iliac joint is not primary in this deformity; it is 
secondary, and is not always present. 

Diagnosis. The diagnosis of the Naegele pelvis, especially where only 
part of the sacral ala is wanting, may be a difficult matter. The follow- 
ing measurements should be made with the pelvimeter : (1) From the 
anterior superior spine of one side to the posterior superior of the oppo- 
site; (2) from the posterior superior spine of one side to the tuber ischii 
of the other; (3) from the spine of the last lumbar vertebra to the anterior 
superior iliac spines of both sides; (4) from the posterior superior spine 
to the great trochanter on the opposite side; (5) from the lower margin 
of the symphysis to the posterior superior iliac spines. 

These right and left measurements must be compared. Normally they 
should be equal or nearly equal. In the marked Naegele pelvis there is 
a considerable difference. Two other measurements may also be made, 
viz., from the middle line of the back to the posterior superior iliac 
spines; from the lower edge of the symphysis to the ischial spines, and 
from these spines to the nearest point of the sacrum. 

Internal examination of the pelvic cavity must be made in order to 
detect the displacement of the lower portion of the os innominatum on 
the diseased side. 

Influence on Labor. If the pelvis is roomy or the deformity 
slight, there may be no delay in the labor. When the contraction affects 
the passage of the head the mechanism by which it attempts to pass the 
brim is the same as in the case of a justo-minor pelvis — i. e., by extreme 
flexion, the antero-posterior diameter of the head being in relation to the 
long oblique diameter of the pelvis. As the head descends it may fail 
to rotate to the front, and may turn to the back. 

In a small pelvis with much contraction delivery is impossible. 
Treatment. The axis-traction forceps should be tried where there 
is delay. Version is recommended by some, but owing to the nature of 
the contraction the former method is most indicated. Embryulcia has 
been used. 

Premature labor may be induced as an alternative method. In extreme 
degrees of contraction Cesarean section should be tried. 

Symphyseotomy should not be employed, owing to the anchylosis of 
the sacro-iliac joint. 

(6) By Imperfect or Abolished Use of One Limb. This may follow 



A XO MA LIES OF THE PASSAGES. 



439 



unilateral disease of a hip or thigh in early life, if the person has been 
forced to use the sound limb to an excessive amount. The weight of the 
body is transmitted down the sound limb, and there results a flattening 
or curving inward of the os iunominatum on that side in the region of 
the acetabulum. On the diseased side there is usually some degree of 
compensatory bulging outward of the corresponding portion of bone. 

The same effect is brought about by amputation of one leg or by an 
old-standing dislocation. 

(c) By Lateral Curvature of the Spine (see page 448). 

4. Transversely Contracted Pelves. 

(a) By Imperfect Development of Both Sacral Alae (Robert Pelvis). This 
is a very rare deformity. The conditions are the same as in a Naegele 

Fig. 270. 




Transversely contracted pelvis. (After E. Martin.) 

pelvis, only both sides are affected; hence by some authors the pelvis is 
called " doubly obliquely contracted." In a typical, well-marked speci- 
men there is marked approximation of both ossa innominata. The 



Fig. 271. 




Diagram showing outline of brim of normal and of Robert's transversely contracted pelvis. 
Black, normal. Red, transversely contracted. 

men there is marked approximation of both ossa innominata. The 
sacrum is narrow, and is rectangular, not triangular. It is nearly 



440 



PATHOLOGY OF LABOR. 



straight in its vertical direction. The ilia extend somewhat behind the 
sacrum, and there is a tendency to shortening of the conjugate of the 
brim. 

In some cases both sides of the sacrum may not be equally maldevel- 
oped. More than the sacral wings may be affected. There is usually 
secondary anchylosis of the sacro-iliac joints. 

Treatment. Cesarean section must be employed. 

(b) By Kyphosis of the Spine (see page 449). 



5. Compressed Pelves. 

(a) Malacosteon. Various degrees of this condition are met with. In 
typical well-marked specimen the following points are noticeable. The 

false pelvis is greatly altered in shape. The 
FlG 272 - iliac fossa?, instead of having the normal 

saucer-like hollowing, are scoop-shaped, ow- 
ing to the marked bending of the iliac 
wings, the anterior superior iliac spines turn- 
ing inward. 

The brim has a characteristic triradiate 
or stellate shape, owing to the approximation 
of the promontory and the acetabula. The 

Fig. 273. 




Diagram showing difference be- 
tween normal and malacosteon pel- 
vis on vertical mesial section. 

Black, normal. 

Red, malacosteon. 




Diagram showing outline of brim of normal and of mala- 
costeon pelvis. 
Black, normal. Red, malacosteon. 



pubic bones are close together, forming a kind of projection or beak. 
Hence this pelvis is often known as the rostrate or beak-shaped pelvis. 
The pubic arch is very narrow. The descending rami may be somewhat 
twisted. The ischial tuberosities are approximated and may be some- 
what bent. The lower end of the sacrum with the coccyx is curved up- 
ward into the pelvic canal. 

Etiology. The deformity is brought about when the pelvis is soft- 
ened by the disease, osteomalacia (mollities ossium). This condition 
usually develops in the puerperium, but may occur in pregnancy. There 
is a removal of the lime salts from the bones. In the softened condition 
of the pelvis it is easy to understand how the weight of the body, the 
resistance of the lower limbs at the acetabulum, and the sitting posture 
may result in a crushing in of the pelvis, as has just been described. 

Diagnosis. The diagnosis is based on the history of the case and on 
external and internal examination of the pelvis. The gait is generally 



ANOMALIES OF THE PASSAGES. 



441 



peculiar : the body rotates greatly as one foot is advanced in front of the 
other. 

Influence on Labor. In the softened condition of the bones labor 
may proceed naturally, though there are great dangers to the mother. 



Fig. 274. 




Malacosteon pelvis, seen from above. (After Wikckel.) 



In eighty-five cases collected by Litzmann there was a mortality of forty- 
seven. Iu the hardened condition, natural delivery is, in the great 
majority of cases, impossible 



Fig. 275. 




Malacosteou pelvis seen from front. (After Winckel.) 

Treatment. In the softened condition of the bones forceps and ver- 
sion have been employed to aid delivery. Now, however, in these cases 
it is extremely likely that Cesarean section with removal of the ovaries, 
or Porro's operation, will be employed, because of the curative influence 
which extirpation of the ovaries exerts on the disease. 

When the bones are hard and the deformity fixed, the procedure 
depends upon the degree of contraction. 

Embryulcia may sometimes be employed, but in the great majority of 
cases Cesarean section must be carried out. 

(b) Pseudo-malacosteon Rachitic. This form has already been alluded 
to in connection with rickets. 

The pubis projects as a beak, the acetabula being somewhat pressed 



442 



PATHOLOGY OF LABOR. 



inward. The iliac wings are not scoop-shaped, as in the true malacosteon, 
but are widely separated anteriorly, as in the typical rachitic condition. 
Etiology. This condition is due to rickets (see page 433). 




Pseduo-malacosteon rachitic pelvis. (After Scheoeder.) 
Fig. 277. 





Front and back view of woman with moderate degree of spondylolisthesis. (After Winckel.) 

6. Spondylolisthetic Pelvis. 

The characteristic feature in this deformity is the projection of the 
lower lumbar vertebra? into the true pelvis, owing to their downward 



ANOMALIES OF THE PASSAGES. 443 

displacement. The sacrum is pushed somewhat backward and down- 
ward, and the symphysis rises. The inclination of the brim is thereby 
greatly lessened. The conjugate of the pelvis is diminished, varying 
according to the amount of descent of the vertebrae. The iliac crests 
are separated somewhat posteriorly. 

The pelvic outlet is narrowed both transversely and antero-posteriorly. 

Etiology. The causation of this condition is not very clear. Injury, 
disease, and developmental errors are believed to be predisposing causes. 
Lane believes that extra pressure from above may bring about the con- 
dition, even when the bone is healthy. 

Diagnosis. The history must be carefully studied. There may have 
been an accident — e. g., a fall, or the woman may have been accustomed 
to carry heavy weights. The height is diminished and the abdomen 
shortened vertically, and it is somewhat pendulous. Seen from behind 
the posterior parts of the iliac crests are very prominent. The articular 
processes of the first sacral and last lumbar vertebrae are very distinct 
below the skin. The ribs are close to the ilia and the flanks are well 
marked. The shoulders are carried well back. When the woman walks 
the footsteps fall in a straight line, the toes not turning outward. Some- 
times she complains of a grating sensation (crepitus) in the lumbar region. 



Fig. 278. 




Spondylolisthetic pelvis. (After E. Martin.') 



Owing to the rotation on the pelvis, the vulvar region is carried for- 
ward. On external examination the symphysis is found to be higher 
than normal, the brim with a lessened inclination, the distance between 
the posterior superior iliac spines increased, and the external conjugate 
of Baudelocque diminished. 

On internal examination the projection of the lumbar vertebrae is dis- 
tinguished, as well as the contracted outlet. The iliac vessels are lower 
than normal, and it may be possible to feel the lower end of the aorta. 



444 



PATHOLOGY OF LABOR. 



The diagonal conjugate must be measured from that point on the lumbar 
projection nearest the symphysis. Owing to the variations in the incli- 
nation of the pelvis and in the degree of deformity, there is no constant 
relationship between the diagonal and true conjugates. The former is 
generally a little greater, but it may be equal to or less than the latter in 
a few cases. 

Influence on Labor. The deformity being of the nature of a 
flattening of the pelvis, the mechanism of labor, providing the head can 
be born, resembles that found in a flat rachitic pelvis. In some cases 



Fig. 279. 



Fig. 280. 



Fig. 281. 




i 






IHi 


in 


iii 


i c 


s 




Different views of a woman possessing a spondylolisthetic pelvis. (After Ahlfeld.) 

natural delivery is impossible. Bad ruptures of the pelvic floor are 
common. 

Treatment. Labor is conducted on practically the same lines as 
laid down in connection with rachitic pelves. 



7. Pelves Distorted by Injuries, Disease, Tumors, etc. 

(a) Double Dislocation Backward of the Femora. This rare condition is 
generally congenital. It results in marked rotation forward of the 
sacrum, increased width of the pelvic cavity and outlet, the tuberosities 
of the ischium being dragged outward, upward, and backward. 

(6) Tumors. The commonest are exostoses at the joints — e. g., sacro- 



ANOMALIES OF THE PASSAGES. 



445 



iliac, symphysis, promontory, sacral. They may be sharp or rounded, 
and vary greatly in size. They may also occur on the ileo-pectineal line. 




Bony outgrowth of right half of pelvis. (After Winckel.) 

These exostoses may interfere with normal labor, and they may injure 
both maternal and fcetal parts. 

Fig. 283. 




Malignant growth of posterior wall of pelvis which necessitated Csesarean section in a case of 

Dr. Cameron. 

Other tumors of the bone may distort the pelvis — e. g., fibroma, sar- 
coma, carcinoma, enchondroma, cysts. Cystic conditions occur in sar- 
coma, enchondroma, and hydatids. Carcinoma is always a secondary 
growth; it may lead to great softening of the bone. 

Tkeatment. Where the growth is too large to admit of delivery by 
the natural passages, Csesarean section or embryulcia must be performed. 
Symphyseotomy is sometimes performed in these cases, but not where the 



446 PATHOLOGY OF LABOR. 

sacro-iliac joints are involved in the tumor. Embryulcia is to be espe- 
cially considered if the child be dead. 

(c) Fractures of the Pelvis. Deformity due to this injury is very rare. 
It may result from bad union of the broken bone, from marked callus- 
formation, or from ossification of the joints near the fracture. 

(d) Anchylosis of Joints. This condition may occur in any pelvic joint. 
When at the symphysis, it is not a serious matter as regards labor; but 
it makes symphyseotomy a more difficult operation. 

In the sacro-iliac joints it is a more serious matter. When it occurs 
in early life it may interfere somewhat with the development of the 
adjacent parts of the sacrum and ilium, and so the pelvis may be some- 
what obliquely contracted. This is a rare condition, however. 

The sacro-coccygeal and coccygeal joints may sometimes become an- 
chylosed. More commonly the sacro-coccygeal alone is affected. In 
the former case there may be marked obstruction to labor, and fracture 
of the coccyx may result. 

Fig. 284. 




Split pelvis. (After Kleinwachter.) 

(e) Split Pelvis. This is a rare condition, being due to a maldevelop- 
ment in the anterior wall of the pelvis. It is not a cause of delay in 
labor, but is rather apt to be associated with rapid delivery. 

8. Pelvic Deformities Due to Spinal Curvature. 

(a) Kyphotic. This deformity varies greatly, according to the extent 
of the kyphosis. The nearer the sacrum the spinal hump, and the more 
prominent it is, the more marked the changes in the pelvis. Generally 
the kyphosis is in the region of the junction of the dorsal and lumbar 
vertebra?. 

Owing to the spinal curvature the centre of gravity of the body above 
it is thrown forward. Some degree of lordosis is brought about by way 
of compensation, but this is not sufficient, and a rotation of the sacrum 
occurs, so that the upper end is thrown backward and downward. There 
is also a rotation of the ossa innominata upon their antero-posterior axes. 



ASOJIALIES OF THE PASSAGES. 



447 



The characteristic alteration in the pelvis is the change in the brim, 
from the normal heart-shape to an oval, in which the long diameter is 
antero-posterior. This results from the backward movement of the prom- 
ontorv, whose prominence may entirely disappear. The sacrum becomes 
longer, narrower, and straighter. The posterior superior iliac spines are 
drawn nearer to each other and the anterior are separated. 



Fig. 285. 




Kyphotic pelvis. (After Kleinwachter.) 



The pelvic canal may become markedly funnel-shaped, owing to the 
movement forward of the lower part of the sacrum, and to the approxi- 
mation of the ischial tuberosities; but many variations are found in the 
degree of contraction. The lower the kyphosis the more will the portion 
of the spine which projects forward tend to interfere with the brim. 



Fig. 286. 



Fig. 287. 





Diagram showing outline of brim of normal 
and of kyphotic pelvis. Black, normal. Red, 
kyphotic. 



Diagram showing outline of brim of normal 
and of scoliotic pelvis. Black, normal. Red, 
scoliotic. 



Sometimes the upper part of the sacrum may be affected by the necrosis 
which has caused the kyphosis, and some extra deformity may thus be 
brought about in the sacrum. 

Diagnosis. The diagnosis is easy from examination and from the 



448 PATHOLOGY OF LABOR. 

woman's history. The condition of the cavity and outlet especially 
must be noted with extreme care. 

Influence on Labor. The obstruction to labor occurs in the lower 
part of the pelvic canal. If the degree of contraction is slight, labor 
may be easy and quick. So frequently may this be the case that a say- 
ing is common in some parts of Europe to the effect that " Hunchbacks 
have easy labors." In a marked degree there is delay, and abnor- 
mal rotation of the head is apt to occur. In a more marked degree of 
contraction birth is impossible. There is special danger of post-partum 
hemorrhage, owing to the imperfect filling of the upper part of the 
pelvis by the uterus. 

Treatment. This varies according to the degree of contraction. 
In slight cases forceps may be used successfully. In worse cases embry- 
ulcia or premature labor may be necessary. In extreme contraction 
Csesarean section is demanded. 




Kyphoscoliotic-rachitic pelvis. (After Ahlfeld.) 

(6) Scoliotic. When lateral curvature affects the spine its effect on the 
pelvis depends on its situation and extent. The lower the bend in the 
spine and the earlier its occurrence, the more marked will be the pelvic 
deformity. As scoliosis is generally associated with rachitis, the scoliotic 
pelvis will show certain changes due to that disease. The special altera- 
tions induced by the spinal condition are as follows : That half of the 
pelvis toward which the convexity of the curvature is directed receives 
an extra amount of the weight of the body. The innominate bone, there- 
fore, on that side tends to be pushed upward, backward, and inward by 
the resistance of the femur. The acetabulum is curved in somewhat 
toward the sacrum, so that the shortest diameter of the brim is that 
between the promontory and the ilio-pectineal eminence, the so-called 



AX03IALIES OF THE PASSAGES. 



449 



sacro-cotyloid diameter. There is also some rotation of the lumbar 
vertebra? toward the side of the convexity. If there is much rachitis 
the promontory may be well forward, the sacral wing on the side of the 
spinal convexity being prominent. Thus the marked deformity is seen 
to be on the side of the convexity. 

Influence on Labor. When only slight degrees of deformity exist 
the child is born by the mechanism observed in the case of the rachitic 
pelvis. If the deformity be more marked, one-half of the pelvis, viz., 
that on the side of the convexity, is of no use, and the head may attempt 
to pass the larger part of the brim by a mechanism like that seen in a 
universally contracted pelvis. Embryulcia has been employed in some of 
these cases. Symphyseotomy has also been tried. But, practically, in 
all cases where deformity is at all marked, Cesarean section is indicated. 

(c) Kyphoscoliotic. Rachitis may cause both kyphosis and scoliosis in 
the same woman. If both are situated low in the spine the pelvis may 



Fig. 289. 



Fig. 290. 




/ 






Views of a woman with kyphoscolio-raehitie pelvis. (After Martin and Fassbender.) 

show certain characteristics due to both these conditions. Generally the 
kyphosis is situated high in the dorsal region, and is compensated for by 
a lumbar lordosis, so that the pelvis is not affected by the kyphotic 
curvature. 

(d) Lordosis. Primary lordosis is so rare a condition that no notice 

29 



450 



PATHOLOGY OF LABOR. 



need be taken of it in this connection. It is usually secondary to spinal 
disease or to pelvic deformity. 

If low down in the spine, it may interfere with the uterus in pregnancy 
and with the entrance of the child in the brim during labor. 



Pelvic Deformity in Relation to the Post-partum State. 

That a deformed pelvis may exert a marked influence on the character 
of the post-partum state is not generally recognized ; yet careful observa- 
tions show that the relationship is one which cannot be ignored. 

Some years ago it was the writer's good fortune to be able to investi- 
gate the cadavera of a number of women who died at various periods in 

Fig. 291. 




Vertical mesial section of a contracted pelvis, from a woman who died a half-hour after delivery, 

of post-partum hemorrhage. 
a. Umbilicus; b, retraction ring: c, cervix: d, posterior fornix; e, tip of coccyx: /, urethra, 

g, urethral orifice. (Stuatz.j 

the puerperium, of conditions not affecting the normal relationships of 
the pelvic contents. By means of frozen sections it was possible to 
describe accurately, for the first time, the topography of the puerperal 
pelvis. Sections showed that in the normal state, immediately after the 
third stage, the retracted and contracted uterine body fills the greater 



ASOJIALIES OF THE PASSAGES. 



451 



part of the pelvic cavity and compresses the extra-uterine tissues, this 
compression being especially marked between the uterus and the bony 
wall, and to a much less extent interiorly,, owing to the softening and 
relaxation of the fascial and muscular tissues of the floor of the pelvis. 
In consequence of this arrangement the circulation of the blood in the 
extra-uterine pelvic structures is considerably interfered with, those parts 
inferior to the body of the uterus — viz., the cervix, vaginal walls, peri- 
neum, and subpubic tissues — being congested, while those tissues com- 
pressed between the pelvic wall and uterine body are anaemic, many of 
the vessels being closed or nearly closed. In the uterine body itself 



Fig. 292 




Vertical mesial section of a kyphotic pelvis, from a woman who died one and a half hours after 
delivery, of post-partum hemorrhage. 

a, intestines ; b, last lumbar vertebra ; c, uterus ; d, peritoneum ; e, placental site ; f, uterine 
cavity ; g, rectum ; h, pouch of Douglas ; i, cervix ; j, cervical canal ; k, cellular tissue ; I, bladder ; 
m, vein ; n, symphysis pubis ; o, urethra ; p, cellular tissue : v, vagina ; w, anus. (Barbour.) 



there is marked anaemia, owing to the compression of vessels bv the 
retracted and contracted musculature. This condition of things lasts 
for the first four days of the puerperium. Both as a result of the state 
of the uterus and of the compression «of extra-uterine tissues bv the 
organ against the pelvic wall, bleeding from its inner surface is greatly 
interfered with, while a marked influence is exerted bv the greatly 
altered circulation in the direction of initiating or assisting the retro- 
gressive changes which cause uterine involution. Further, the condi- 



452 PATHOLOGY OF LABOR. 

tion of the cervix and vagina aids to an understanding why after labor 
there is so often bleeding as a result of tears ; and why, if the lacera- 
tion has extended into the paracervical and paravaginal tissues so rich 
in venous sinuses, there may be very severe hemorrhages. 

During several years the writer has made careful observations regard- 
ing post-partum hemorrhage in cases of normal and abnormal pelves, 
and he has found it to be most profuse and most difficult to check in 
women with abnormally large pelves and in those with abnormally 
contracted pelves. Of the former, may be mentioned the justo-major 
or universally enlarged, and the kyphotic, in which the upper part of 
the pelvic cavity is much increased ; of the latter I may mention the 
rickety pelvis. The explanation of these facts is very evident from 
the study of cadavera. Barbour, of Edinburgh, has published an inter- 
esting case of a kyphotic woman who died one and a half hours after 
delivery, of post-partum hemorrhage, and his sections of the frozen body 
show that the uterus in ho way acts as a plug to the large size of 
the upper part of the pelvic cavity, the extra-uterine tissues being 
markedly congested, the large vessels dilated — conditions all favorable 
to excessive bleeding. On the other hand, in the case of a well-marked 
contracted brim, as is shown by Stratz's section of a rickety woman who 
died of post-partum hemorrhage one-half hour after delivery, the uterus 
cannot sink down into the pelvis, the cervix, vagina, and extra-uterine 
pelvic tissues being thereby allowed to become enormously congested. 

The Prevention of Dystocia. 

During the last century various attempts were made to influence the 
growth of the foetus during its intra-uterine life, so that labor might be 
rendered less difficult in cases in which there had been dystocia. These 
consisted in purging, bleeding, or underfeeding the mother. 

In 1841 Rowbotham, a London chemist, published a pamphlet de- 
scribing the success which had followed the treatment of his wife by 
restriction of her diet. For many years his system was carried out 
among the laity, but was little noticed by the profession. 

In 1889 Prochownick gave an account of some cases in which he 
claimed that pregnancy had been made to terminate in satisfactory full- 
time labors by dietetic restrictions to which the mothers were subjected 
during the last two months of pregnancy. He believed that this method 
of treatment would result in the development of a small foetus, which 
might in a large percentage of women with contracted pelves be born at 
full time, thus rendering serious operations and induced premature labor 
less frequently necessary. He emphasizes the increased capacity of the 
skull for moulding. 

His diet was as follows : 

Morning : Small cup of coffee and 6 drachms of Zwieback. 

Xoon: Any kind of meat, eggs, or fish, with very little sauce. Some 
green vegetable, with fat added. Salad, cheese. 

Evening: As above, with addition of li ounces of bread. Butter as 
desired. 

Fluids, per diem, limited to 12 or 15 ounces of red or Moselle 
wine. 



AX03IALIES OF THE PASSAGES. 453 

To be entirely avoided : Water, soups, potatoes, cereals, sugar, beer. 

Several workers have reported successful cases treated by Prochow- 
nick's method, but it has not been sufficiently tested to warrant its 
widespread adoption. 



B. Soft Parts. 
1. Uterus. 

Developmental Anomalies. 

When labor takes place in the case of a unicornate uterus there are 
apt to be malpresentatious and positions, mainly owing to the inclination 
of the long axis of the cornu to the pelvic canal. 

In the case of pregnancy in one horn of a bicornate uterus the same 
tendency exists. Here also labor may be obstructed by the recto-vesical 
ligament which runs between the cornua. Where both horns are preg- 
nant obstruction is likely to occur from jamming together of the twins. 

In the case of a pregnancy in one half of a septate uterus, the unim- 
pregnated half may act as a mechanical obstruction or the septum may 
do this. 

In all these cases the labor pains may often be weak, short, and ineffi- 
cient. Rupture of the uterus may occur. Severe post-partum hemor- 
rhage may result. 

Treatment. It may be necessary to assist delivery by version or 
forceps. In such cases the greatest care should be used in order that 
the uterine wall be not ruptured. Version should be employed as little 
as possible. Embryulcia or Cesarean section may be necessary some- 
times. When a septum is an obstruction it may be cut through. 

When pregnancy occurs in the rudimentary horn of a bicornate uterus, 
the case is very grave and must be treated as one of tubal gestation. 

Atresia of the Cervix. 

This is acquired after conception, usually from the use of escharotics, 
and is seldom complete. Generally a dimple exists at the site of the os 
externum. If the condition be not relieved rupture of the uterus will 
take place. 

Treatment. With a sound a small opening may be made through 
the dimple. Sometimes it is necessary to make a crucial incision. Dila- 
tation usually follows naturally. If there is sharp bleeding, ligatures 
may be necessary. 

Rigidity of the Cervix. 

This condition causes delay in the first stage of labor. It may be 
functional or organic. Functional rigidity is either constitutional — e. g., 
as met in elderly primiparse, or spasmodic. In the latter condition, the 
cervical sphincters do not relax between the pains, and the os externum 
tends to become smaller during the pains. This condition is usually 
associated with inefficient contractions of the body of the uterus. 



454 



PATHOLOGY OF LABOR. 



Organic rigidity is due to various causes. Former lacerations may- 
have led to the formation of much cicatricial tissue in the cervix, or this 
condition may succeed operative procedures. 

Syphilitic changes or new growths sometimes cause rigidity. 



Fig. 293. 




Stenosis of the cervix uteri obstructing labor. (After Jektzer.) 

Treatment. In the constitutional, spasmodic, and inflammatory vari- 
eties, hot douches, frequently given, are serviceable. Chloral, morphia 
suppositories, or large doses of opium in pills may be administered. Large 
doses of chloral are to be preferred, because this drug causes dilatation 
painlessly without interfering with the pains; morphia tends to suspend 
the pains. If the patient be exhausted chloroform may be given, and a 
hypodermic of morphia to induce sleep for a few hours. 

It may be necessary to assist dilatation by separating the membranes 
from the lower uterine segment as much as possible and by pressing the 
lips of the cervix apart with the fingers. Rubber dilators, e. g., Barnes's 
or Champetier de Ribes's, are valuable when the other methods fail. 

Sometimes several incisions, one-half inch deep, must be made in the 
cervix. These should immediately precede artificial delivery. 



Impaction of the Cervix. 

In the case of rigid cervix, hypertrophy of the cervix, or in pendulous 
belly, where the os externum is directed to the back, the anterior lip may 
bo caught between the head and the pubes, and, becoming swollen and 
oedematous, may impede labor, or, after labor, may slough. In these 



AS OM A LIES OF THE PASSAGES. 



455 



eases attempts should be made to push the cervix up between the pains. 
When this is impossible, it is best to draw the head through with forceps 
or to make incisious in the cervix. 

Malpositions of the UteruSo 

Anteversion. When there is marked anteversion in pendulous belly, 
or as a result of separated recti, the uterine force may be so badly directed 
that dilatation takes place very slowly. 

Treatment. The patient is kept on her back, an abdominal binder 
being used to hold the uterus in position. 

Hernia. A pregnant uterus may fall into an umbilical hernia or into 
a ventral hernia following a laparotomy. Sometimes an inguinal hernia 
may contain a pregnant uterus. 



Fig. 294. 




Retroflexion of the gravid uterus. (After Schatz.) 

Treatment. The dorsal position and the binder are employed to 
keep the uterine axis properly directed. In the case of an inguinal 
hernia the child may be delivered by version, and the uterus afterward 
withdrawn from the hernia. But it is probably best to open the hernial 
sac, removing the foetus from the womb and amputating the latter. This 
condition is usually found with a unicornate or bicornate uterus. 



456 PATHOLOGY OF LABOR. 

Latero-version. Marked tilting of the fundus to one or other side may 
sometimes occur. The patient should be placed on the side toward which 
the fundus is directed, aud a pillow should be put under that side of the 
belly during labor. 

Sacculation. Where a retroflexion of the gravid uterus has occurred 
in the early months, the pregnancy having advanced to term, there may 
be formed* a kiud of diverticulum behind the cervix, the latter being 
usually above the brim against the abdominal wall. The posterior vaginal 
wall is markedly bulged downward and forward, and the foetal parts may 
be so easily felt as to suggest an ectopic gestation; or the projecting 
vagina may be mistaken for a bag of membranes. 

Treatment. The cervix should be dilated artificially and version 
performed. It may be necessary sometimes to perform Cesarean section. 

Prolapsus Uteri. Complete prolapse of the pregnant uterus is un- 
known. Various degrees of partial prolapse have been met with. 

Often when pains set in the prolapsed portion is drawn up. But if 
the cervix be rigid or much hyper trophied, this does not happen, and 
the prolapsed portion may become oedematous, and, consequently, more 
pronounced. 

Treatment. See " Impaction of the Cervix." 

Labor in Cases in which previous Operative Measures for 
Displacement of the Uterus have been carried out. 

It is too soon to decide as to the frequency of complications in labor 
due to the various operations which have been carried out for displace- 
ments of the uterus. Only an approximate idea of their relative im- 
portance can be given. 

Shortening of the round ligaments by all methods has rarely been 
reported as causing trouble in labor. 

Vaginal fixation and ventro-fixation are the most serious causes of 
trouble, the former more frequently than the latter. Malpresentations 
and malpositions of the foetus, inertia uteri, rupture of the uterus, and 
post-partum hemorrhage are among the most frequent complications. 
A considerable percentage of obstetric operations have been neces- 
sary. 

Ventro-suspension is very infrequently followed by difficulty in labor. 
This is explained by the stretching or breaking of the fibrous suspensory 
ligaments which support the uterus from the abdominal wall. 

New Growths of the Uterus. 

1. Fibromyoma. Fibromyomata are not common causes of trouble in 
labor. It is impossible accurately to group the disturbances which occur 
in relation to the various forms of tumor met with, viz., submucous, sub- 
peritoneal, and interstitial. 

The most dangerous as regards labor are those in the region of the cer- 
vix. These may lead to malpresentations and malpositions of the foetus, 
to obstruction in labor, to prolapse of the cord, to adherent placenta, and 
to post-partum hemorrhage. Labor-pains may be very irregular, often 
inefficient ; sometimes a tetanic condition is met with. Laceration of 



AX03IALIES OF THE PASSAGES. 



457 



the uterus may occur. Contusions and fractures of the foetal skull may 
be caused. Death may occur in some cases if interference be not carried 
out. 

In the puerperium there is increased risk of inflammation and septic 
infection, or, in the case of a submucous tumor, of necrosis. 

Sometimes the contractions of the uterus may displace above the brim 
a small tumor which had lain below it on the anterior wall. 

Spontaneous enucleation of a submucous fibroid may occur during or 
immediately after delivery. 

Diagnosis. The diagnosis is not, as a rule, difficult, save when the 
fibroid is on the posterior wall or projecting into the cavity of the uterus. 
When they can be felt they are generally easily recognized. They may 
be mistaken for parts of the fcetus, for twins, or for portions of placenta. 

Treatment. In some cases of fibroid — e. g., subperitoneal oues high 
up in the body — the labor may go on perfectly naturally. In cases where 



Fig. 295. 




ffecfo/7} 



Perineum 



Myoma uteri complicating pregnancy. (After Spiegelberg.) 



there are several small fibroids or a large one high up in the wall, the 
pains may be weak and labor prolonged. In such a case version or for- 
ceps may be employed. Interference should be carried out early, because 
the risks to the mother are greater the longer the delay. 

When a small tumor is felt so low down as to be a source of obstruction, 
it should be carefully examined, in order that it may be known whether 
or not it may be pushed upward. Attempts may be made to push the 
tumor up, the patient being in the lateral, dorsal, or genupectoral posture. 
Anaesthesia may be necessary to carry out this procedure. If this is im- 
possible, the further treatment depends on the amount of contraction. 
It may be so slight that delivery by version or forceps may be performed ; 



458 PATHOLOGY OF LABOR. 

Walcher's position may sometimes assist delivery. If greater, embry- 
ulcia or Cesarean section is necessary. Should such a case be under 
observation during the course of pregnancy, the induction of premature 
labor may sometimes be a safe method of procedure. 

Polypoidal fibroids of the cervix may be removed before or during 
delivery. Non-pediculated ones of the cervix may be enucleated artifi- 
cially. 

Where a very large fibroid of the body or several small ones cause 
marked obstruction, Cesarean section or Porro's operation should be 
decided upon. 

In all cases in which delivery is effected through the vagina the 
greatest care must be exercised in the treatment of the third stage. The 
placenta may be adherent and may require separation. Hemorrhage 
may be profuse, from the imperfect contraction and retraction of the 
uterus, or from the opening of vessels in the capsule of a submucous 
fibroid. The hot intra-uterine douche must be used, as well as hypo- 
dermic injections of ergotin. The best method of controlling hemor- 
rhage, however, is to pack the uterus and vagina with sterilized iodoform 
gauze. This may be left in situ for three or four days, and then may be 
renewed if necessary. 

If a submucous tumor tends to become enucleated it should be removed 
early, in order to diminish the risk of necrosis and suppuration. 

It is interesting to note that uterine fibroids often get smaller and 
sometimes disappear after labor. 

2. Carcinoma of the Cervix. This condition may be found at full time, 
and may be a cause of trouble in labor. Sometimes, if the disease be 
early and localized, the labor may go on naturally. If the cancer be 
advanced and infiltrating surrounding tissues, and the case be left to 
nature, the pains may be intermittent for days, the patient getting weak- 
ened, and the child usually dying. Rupture of the cervix may occur, 
leading to bad hemorrhage or to sepsis. 

Treatment. If the case is observed during early pregnancy in the 
localized state of the new-growth, total extirpation of the uterus by the 
vagina may be carried out. Later in pregnancy premature labor may be 
induced and amputation of the cervix or extirpation of the uterus afterward 
carried out, or abdominal extirpation of the uterus may be performed. 

At full time, when the cervical cancer is not too extensive, some prefer 
to perform embryulcia, if a living child cannot be delivered. Opinion 
is, however, tending more to favor the performance of Cesarean section 
in all cases where the disease is at all marked. But whenever there is 
a chance that the cancer may be entirely removed, Porro's operation 
should be carried out. 

Duhrssen has recommended the vaginal route for certain cases. The 
uterus is drawn down, the bladder dissected from its wall and pushed 
upward, and an opening made into the uterine cavity, through which 
the foetus is extracted. The uterus is then removed. 



ANOMALIES OF THE PASSAGES. 459 

Stenosis of Vagina and Vulva and Eigidity of Tissues. 

Sometimes the vagina may be double, or have longitudinal or trans- 
verse septa. Rarely, it may be markedly atresic. 

Treatment. Septa should be divided. An atresic portion may be 
dilated if it be not too extensive. Incisions may be necessary. Bat 
sometimes embryulcia or Csesarean section may be indicated. 

The hynien may be a cause of obstruction and may require incision or 
removal. 

The vagina and vulva may be narrow and tough in elderly primiparse, 
in very muscular women, aud in conditions of cicatricial contraction after 
previous injury. 

Treatment. Hot douches, emollients, and warm sponges serve some- 
what to softeu the parts. Dilatation may be promoted by means of arti- 
ficial dilators — e. g., Barnes's or Champetier de Ribes's bag. 1 If the 
perineum is so rigid that it will not stretch well, and if a rupture is 
feared, episiotomy should be carried out with scissors, a cut being made 
through the edge on each side a short distance from the middle line. 
This procedure saves the risk of a tear into the anus. The cuts can be 
closed after delivery, if they are large. It is to be remembered that 
labor may be expedited in a case of rigid perineum if the patient be 
placed in Walcher's position. 

Where cicatrization of the vagina does not yield to hydrostatic dilata- 
tion, accompanied with superficial incisions sufficient to permit of delivery 
by version or forceps, Cesarean section is necessary. 

Swellings of the Vagina and Vulva. 

Hsematoma. This condition may be found in the labia, the perineum, 
or the vaginal walls. Though it mostly occurs after labor, it may be a 
cause of delay in labor. Sometimes it may form between the delivery 
of the first and second child in the case of twins. If the mass be large 
enough to obstruct delivery, it should be incised and cleared out, to allow 
of the passage of the foetus. Afterward, if there be slight bleeding, the 
cavity should be packed with iodoform or chinosol gauze. If, however, 
the hemorrhage be severe, it may be necessary to close the cavity from 
side to side with a series of sutures, and to keep up pressure on the sur- 
face by means of a pad and bandage. In the case of a small mass 
delivery may be effected by means of forceps, incision not being 
necessary. 

(Edema of the Vulva. This condition may be due to heart or kidney 
disease, or to delayed labor. The oedematous parts are apt to tear, and 
may become gangrenous afterward. Puncture or incision may be neces- 
sary, but only when absolutely unavoidable, owing to the risk of sepsis 
or gangrene. This procedure must be carried out with strict asepsis. 
Episiotomy may be necessary to save rupture. 

Varicose Veins of Vulva. These very rarely interfere with the passage 
of the head through the vulva. They may rupture or be so bruised as 
to slough afterward. 

1 These dilators must not be overdistended, lest rupture of the vagina be caused. 



460 PATHOLOGY OF LABOR. 

Labial Abscess. If this is large enough to obstruct labor, it may be 
opened, scraped out, swabbed with iodized phenol, and stuffed with iodo- 
form or chinosol gauze. 

Solid Tumors of the Vagina and Vulva. Fibromata and fibromyomata 
may occur and may interfere with delivery. The bruising of the tumor 
may lead to after-gangrene. 

Treatment. If these tumors are not recognized until labor comes 
on, it may be possible to remove them by enucleation or by amputation 
of the pedunculated forms. AVhere this is not considered advisable, for- 
ceps may be used if the vagina is not too much contracted. There is 
danger of causing after-sloughing of tissues if there be a prolonged use 
of the forceps. Rarely embryulcia or Csesarean section may be necessary. 

Cysts. These may obstruct labor. Puncture is usually sufficient to 
promote delivery. A pediculated cyst may be removed easily during 
labor. 

Enterocele. Vaginal enterocele 'may be either anterior or posterior. 
The latter is most common. The hernial condition may obstruct labor 
when the bowel is distended with gas or with feces. The long-continued 
pressure of the head may lead to a rupture of the sac, or may seriously 
bruise the bowel. 

Treatment. The patient should be placed in the genupectoral posi- 
tion and the hernia reduced. If this is not possible, owing to the low 
position of the presenting part of the foetus, or to adhesions, the child 
should be delivered rapidly with forceps. Should rupture of the sac 
occur the intestines should be cleansed and returned, and a repair opera- 
tion be performed on the posterior vaginal wall. 

If the hernial condition be a very large one, Cesarean section may be 
justifiable. 

Distended Rectum or Colon. Fecal accumulation may delay labor by 
interfering with the powers and by obstructing the passages. The bowel 
must be cleared out with enemata or by repeated flushings by means of 
a funnel and tube. Sometimes it is necessary to scoop out the masses, 
and for this it may be necessary to anaesthetize the patient. 

Sometimes this distention of the rectum may be associated with the 
condition known as anus vaginalis, in which the anus is placed too far 
forward. 

Cancer of the Rectum, if extensive, may be such an obstruction as to 
lead to Csesarean section. 

Conditions of the Bladder. 

Distention. This is a very common cause of delay in labor. The urine 
should be removed with a long, soft catheter. Sometimes this is impos- 
sible, and suprapubic aspiration must be carried out. 

Cystocele or Colpocystocele. This condition may obstruct labor. It may 
be mistaken for an impacted cervix, for the bag of membranes, for the 
caput succedaneum, or for a tumor. 

Treatment. The urine should be drawn off, care being taken to 
pass the catheter downward and backward. The prolapsing part should 
be gradually pushed up above the advancing head. Sometimes it is neces- 



ANOMALIES OF THE PASSAGES 46 i 

sary to deliver the child with forceps, the sacculation being held up by 
an assistant. 

Vesical Calculus. If the calculus be very small, labor may go on nat- 
urally without causing any trouble, but if it is of any size it is apt to be 
very painful, to obstruct delivery, and to lead to injury of bladder and 
vaginal walls. If discovered early in labor it may be pushed above the 
symphysis and removed after labor, in the case of a small one. Some, 
however, think it best to remove it by dilatation of the urethra. If the 
stone be too large to be removed in this way, it should be extracted 
through a mesial incision in the anterior vaginal wall and base of the 
bladder. After labor the incision can be closed. 

Tumors of Neighboring Structures. 

Ovarian Tumors. Ovarian tumors may complicate labor in various 
ways. If of large size they may interfere with the powers and may 
obstruct the passages. They may also cause malpositions and malpre- 
sentations. Small tumors are serious causes of obstruction when they 
lie in the true pelvis. Labor may lead to rupture of the tumor when it 
is cystic, and this may be followed by intra-peritoneal hemorrhage or 
peritonitis; or the tumor wall may be much bruised and inflammation 
and adhesion may result. Twisted pedicle and occlusion of the bowels 
are sometimes caused. Rupture of uterus, vagina, or rectum may occur. 

Diagnosis. This may be difficult in some cases. The tumor may be 
mistaken for a fibroid or for a blood or inflammatory exudation when it 
is situated within the true pelvis. When it is cystic and fluctuation can 
be made out by vaginal examination, the diagnosis is easier. 

When the tumor is above the brim and is not situated behind the 
uterus it may be felt distinct from the uterus, and may be moved unless 
impacted or fixed by adhesions. The abdomen is exceptionally distended, 
and the condition may be mistaken for hydramnios or twins. However, 
no intermittent contractions occur in the wall of the tumor, and it is thus 
distinguished from the uterine wall. 

Treatment. If the woman has begun labor and the tumor be below 
the brim, an effort should be made to push it into the abdomen, anaesthesia 
being used, if necessary. If this fail, some authorities think it best to 
try delivery with forceps, if the obstruction be not too great ; or, if this 
fail, to tap the cyst and deliver with forceps, or to employ embryulcia. 
Others reject these measures, and recommend abdominal section and 
removal of the tumor ; or, in some cases, Csesarean section and re- 
moval. 

The objection to vaginal puncture is that it may be followed by danger 
to the peritoneum by escape of the contents, especially if it be a dermoid. 
If the cyst contain many loculi, puncture may do no good. Also, a 
mistake in diagnosis may be made, and a pyosalpinx, for instance, might 
be opened. 

When the cyst is above the brim delivery may usually be effected by 
version or forceps. 

Other Tumors of the Soft Parts. Broad ligament, tubal, and other 
swellings, if of sufficient size to cause serious obstruction in labor, are 



462 PATHOLOGY OF LABOR. 

best treated by Cesarean section. A hydatid cyst should also be treated 
in this way. 

Inguinal and Crural Hernise. These may be forced clown during labor 
and cause a great increase in pain and excessive straining. It may be 
necessary to hold the hernia back during the pains, or sometimes to 
anaesthetize the patient and deliver by version or forceps. 

Floating Kidney. A kidney may be displaced downward and be adher- 
ent at the brim, or may be deeply placed in the pelvis, causing an ob- 
struction and increasing the patient's suffering greatly. It may be 
necessary to anaesthetize and deliver by version or forceps. 

Runge performed abdominal section in one case, raising the kidney 
out of the pelvis. Albers-Schonberg reports one case in which rupture 
of the uterus was caused. In another, in which the kidney lay in the 
pouch of Douglas, vaginal nephrectomy was carried out ; this was fol- 
lowed by successful labor. 

Tumors of the Liver. Large hydatid cysts and carcinomatous tumors 
may obstruct labor. Version or forceps may be necessary, or Csesarean 
section. 

3. ANOMALIES OF THE FCETUS. 
Malposition of the Head. 

OCCTPITO-POSTERIOR CASES. 

There are two varieties : that in which the long axis of the head 
lies in the right oblique diameter at the beginning of labor — right 
occipito-posterior, R. O. P. — and that in which it lies in the left oblique 
diameter — left occipito-posterior. The former is the more com- 
mon. 

Labor is generally longer in these cases, partly because the head does 
not flex well on entering the pelvis, and so does not become well accom- 
modated to it, and partly because of the long internal rotation. The 
pains in the first stage are often irregular and imperfectly marked. 

Diagnosis. On external examination of the abdomen at the begin- 
ning of labor, the back of the foetus is not felt through the mother's 
anterior abdominal wall. If the parts are lax or thin, the irregular 
projections of the limbs of the foetus may be felt. The head may be 
palpated above the brim. The foetal heart is heard well around in the 
flank between the iliac crest and the ribs. On vaginal examination the 
rounded head is felt through the fornices. When the cervix is opened 
sufficiently to allow the entrance of the fingers, the sagittal suture is felt 
in the line of the oblique diameter, and the posterior fontanelle is in the 
posterior half of the pelvis. 

Mechanism. The normal mechanism in a typical case is as follows : 

Flexion. 

Internal rotation. 

Extension. 

External rotation. 
Flexion goes on slowly, and consists in a movement of the 
occiput downward and inward from its original position near the 



AXOMALIES OF THE FCETUS. 



463 



Fig. 296. 



girdle of contact. Following this movement, the occipital end of 
the head readies the sacral segment of the pelvic floor. As a 
result of this, according to the teaching of 
Berry Hart, internal rotation is brought about, 
the occiput being thrown or directed forward 
until it lies in the middle line anteriorly. The 
rest of the delivery proceeds as in an occipito- 
anterior case. 

Abnormal Occipito-posterior Cases. 1. In some 
cases the head does not flex well on entering the 
brim, owing to a small size of the head. The 
sinciput reaches the sacral segmeut of the pelvic 
floor before the occiput on the opposite side, and 
as a result, according to Hart's law, it is rotated 
to the front of the pelvis, the occiput turning 
into the hollow of the sacrum. Clinically, we 
always speak of this malrotation as a rotation 
of the occiput to the back; but in reality, ac- 
cording to Hart, the essential feature is the an- 
terior rotation of the sincipital end of the head. 

The head may now remain in this position, which is termed " Per- 
sistent Occipito-posterior" or the " Face to Pubes" case. 

But natural expulsion may take place, the face passing under the sym- 
physis and the occiput over the perineum. This is accomplished with 
difficulty, and requires very strong pains, lax maternal parts, and not too 




Diagram showing head un- 
moulded and moulded in a per- 
sistent occipito-posterior case. 
Black, unmoulded. 
Red, moulded. 



Fig. 297 



Fig. 298. 





Right occipito-posterior position of head. The 
arrow shows the direction of the long internal 
rotation made by the occiput in delivery. 



Left occipito-posterior position of head. The 
arrow shows the direction of the long internal 
rotation made by the occiput in delivery. 



large a head. The perineum is generally badly torn. The head flexes 
well before it passes through the outlet. After the birth of the head 
external rotation (really an internal rotation of the shoulders) occurs, and 
the body is born. 

The head-moulding in these cases is as follows: The occipito-mental 
and occipito-frontal diameters are much shortened, the suboccipito-breg- 
matic being lengthened greatly. 

2. In some cases, owing to the disproportion between the occipital end 
of the head and that part of the brim in relation to it, flexion is pre- 
vented, and the head may enter the brim in an extended position, giving 
a brow or face presentation. 



4(54 PATHOLOGY OF LABOR. 

3. In another set of cases the head may enter the brim poorly flexed, 
and on reaching the pelvic floor may rotate only partially, remaining 
fixed in its long diameter, being in the transverse of the pelvic cavity. 

Fig. 299. 




Faulty mechanism in a right occi pi to-posterior case. The occiput is shown rotating to the back. 

(After Schultze.) 

Management of Labor. The case should be carefully watched and 
frequent examinations should be made to determine whether or not flexion 
is taking place to a sufficient extent. If the mechanism goes on satis- 
factorily, the management is the same as in an occipito-anterior case. 

When flexion takes place badly it should be promoted, the sinciput 
being pushed up during the pains. This is best accomplished if the 
patient be placed in the genupectoral posture. 

If this be not successful, some authorities recommend that the woman 
be anaesthetized, the hand passed into the cervix and the head markedly 
flexed by pressing up the sinciput. The anaesthetic should then be 
stopped and the head kept flexed until pains return, forcing it into the 
brim. Should extension again be established, the following methods 
may be adopted : The foetus may be turned and delivered as a breech 
case; or the head and trunk may be rotated by the hand until the occi- 
put is anterior, and then may be delivered with forceps ; or forceps 
may be at once applied while the occiput is posterior. Most physicians 
employ the latter method. 

Application of Forceps in a High Occipito-posterior Case. 
The blades are applied in the ordinary manner — i. e., right and left qua 
the pelvis. As the head is drawn into the cavity rotation tends to occur. 



ANOMALIES OF THE FCETUS. 465 

As a result of this the blades are so altered as to be ill-adapted to the 
pelvic curve, aud they should, therefore, be removed as soon as the head 
is well through the brim. The case may then be left to nature, or the 
forceps may be reapplied. 

Recently Milne Murray has introduced axis-traction forceps for these 
cases to allow of continuous extraction of the head in spite of the rotation 
which occurs. The main feature which allows of this is the lessening 
of the curve of the blades. 

Application of Forceps when the Head is Low in the Pel- 
vis. AYhen the occiput has not rotated to the front or has only partly 
rotated, the forceps will grasp the head obliquely or antero-posteriorly. 
As traction proceeds the head tends to rotate. If this is marked, the 
blades should be removed and reapplied. Between tractions the handles 
should be separated, because sometimes the occiput tends to turn to the 
front spontaneously. 

When the occiput is in the hollow of the sacrum the sinciput should 
be kept well pushed up, in order to promote flexion and to allow head- 
moulding to occur. Then forceps should be applied and delivery brought 
about, the patient being placed in Walcher's position the better to pro- 
tect the perineum. As the head emerges it should flex, the root of the 
nose pivoting under the pubic arch. 

If necessary, the perineum should be incised on each side of the middle 
line to prevent a central rupture. 

Face Presentations. 

Frequency. Face presentations are not common. Various statistics 
are given, from 1 in 200 to 1 in 497. 

Positions. The chin is the denominator and the positions are in order 
of frequency: 

Right mento-posterior, P. M. P. 
Left mento-anterior, L. M. A. 
Left mento-posterior, L. M. P. 
Pight mento-anterior, P. M. A. 
Some authorities believe that left mento-anterior positions are more 
frequent than right mento-posterior. 

Etiology. It is best to regard face presentations as altered vertex 
presentations. They very rarely exist before labor sets in, and, as a 
rule, they develop only as labor proceeds. The causes are varied; they 
may be tabulated as follows: 

1. Enlarged neck or thorax — e. g. y due to tumor. 

2. Coiling of cord around neck. 

3. Folding of arms under chin. 

4. Excessive mobility of fcetus. 

5. Small size of foetus. 

6. Excessive liquor amnii. 

7. Obliquity of uterus. 

8. Sudden escape of liquor amnii. 

9. Flat pelvis. 

10. Certain conditions of occipito-posterior cases, in which there is a 
tight fit at the brim. 

30 



466 



PATHOLOGY OF LABOR. 



By some, dolichocephalic head is given, but it is doubtful if this shape 
ever exists in utero sufficiently marked to bring about a malpresentation. 
It is found after delivery in face cases, but the shape is due to the head- 
moulding. 

The factor in changing a vertex to a face presentation is evidently 
extension, and the student may easily understand how the above causes 
may induce this change. 

Diagnosis. The examination of the mother's abdomen reveals, in 
many cases, nothing different from what is found in a vertex presenta- 
tion. If the abdominal wall be lax, however, it may be possible to feel 
the furrow between the back and the occiput, owing to the extension of 
the head. There is also a lack of application of the body of the foetus 
to the uterus and abdomen. The bulging of the occiput at the side may 
be felt. On vaginal examination early in labor the rounded head felt in 
vertex cases is wanting. The fornix is high up and somewhat irregularly 
flattened across. 

Fig. 300. 




Mechanism of labor in a face case. Right mento-anterior. (After Schultze.) 

When the cervix is somewhat dilated, forehead, nose, malar processes, 
and mouth may be distinguished. If much of a caput succedaneum has 
formed over the face, it may be mistaken for a breech; the mouth being 
mistaken for the anus, the nose for the coccyx, the malar processes for 
the ischial tuberosities, and the cheeks for the nates. Care must be 
taken not to injure an eye in making the examination. 

Prognosis. Labor is slow. The first stage is delayed because the 
head does not fit so well in the lower uterine segment as in a vertex case, 
and does not allow of the formation of so good a bag of waters. Ante- 
rior cases — i. e., those iu which the chin is in front, are better than pos- 
terior, and the labor is quicker. 



ANOMALIES OF THE FCETUS. 467 

In posterior cases malrotation may occur, usually requiring interfer- 
ence; the skull is compressed against the pubes. The maternal risk is 
not greatly over the normal; the risk to the child, compared with vertex 
cases, is computed to be as 13 is to 5. There is more danger of lacera- 
tion of the perineum. 

Mechanism. Normal, (a) In the most common anterior case — 
L. M. A. (this is simply an R. O. P. case in which extension of the 
head has occurred). At first extension of the head goes on slowly, and 
it passes through the brim with its vertical diameter in relation with the 
inlet. As the foetus is pushed down it is evident that that part of the 
head which first reaches the sacral segment of the floor is the chin. It 
reaches the anterior part of the left half of the segment, and, in accord- 
ance with Hart's law, is rotated forward to the middle line under the 
symphysis. When internal rotation is complete, flexion follows. The 
month, nose, eyes, and forehead appear successively. Then the vertex 
comes over the perineum while the chin slides forward under the sym- 
physis. Finally the occiput sweeps over the perineum. Afterward 
external rotation or restitution occurs — in reality a rotation of the shoul- 
ders — and the body is next delivered. 

(6) In the most common posterior case — R. M. P. (this is an L. O. A. 
in which extension has occurred), at first extension of the head occurs. 
Long internal rotation then takes place, whereby the chin is brought to 
the front under the symphysis. The rest of the labor is the same as in 
the case of L. M. A. 

Abnormal, (a) In a large pelvis, sometimes, or in cases where the 
foetus is small, the head may be pushed through the pelvis without any 
special mechanism. 

Its long diameter may be fouud in relation with any diameter of the 
pelvis. In the flat rachitic pelvis it usually passes with its long diam- 
eter in the transverse. These abnormal de- 
liveries are most favored by death of the fig.3ol 
foetus, when its tissues become more lax. 

(b) Sometimes, in men to-posterior cases, 
abnormal internal rotation occurs, so that the 
chin, instead of being carried to the front, is 
turned to the hollow of the sacrum. Accord- 
ing to Hart, the explanation of this condition 
is as follows : It only occurs when the pelvis 
is very large or the head small. Extension 
of the head is imperfect, and the chin does 
not strike the sacral segment on its own side. 

It is the sinciput which Strikes the Opposite Diagram showing head un- 

segment, and is, therefore, rotated to the front. moulded * nd moulded + by labor in 

x , i 1n , . i i ., -i.. a case of face presentation. 

In other words, that which we describe clini- Black unmoulded# 

cally as a rotation of the chin to the back is Red, moulded. 

really a forward movement of the sinciput. 

This condition is a bad one. It is very rare that natural delivery fol- 
lows, and then only when the head is very much smaller than the pelvic 
cavity. It is apt to become arrested, being then known asa u persist- 
ent mento-posterior" case. The reason of this is evident. The chin 
is jammed in the curve of the sacrum, and if the head is to be born 




468 PATHOLOGY OF LABOR. 

the coccyx must be excessively bent back, the sacro-sciatic ligaments 
and perineum greatly stretched, and the cranial vault greatly flattened. 

Head-moulding. After an ordinary face delivery the vault of the 
head is seen to be flattened, the supra-occipital being pushed backward 
and the convexity of the frontals increased. The transverse, occipito- 
frontal, and occipito-mental diameters are increased, the suboccipito- 
bregmatic lessened. 

The caput succedaneum is found on the face : in mento-posterior 
cases in the upper malar region and region of the eye (thus, in the 
R. M. P. case, on the right side of the face); in mento-anterior cases in 
the lower malar region, about the augle of the mouth (thus in L. M. A., 
on the left side of the face). In other words, the caput is formed over 
that part which has been especially placed in relation to the deficiency in 
the anterior pelvic wall below the pubes. The skin may be greatly dis- 
colored. The eye may be closed for some days, or the mouth may be 
incapable of suckling for a short time. 

Management. The bag of membranes should be preserved as long 
as possible, because the face is so poor a dilator. Sometimes the case 
may be left to nature — i. e., when the woman is a multipara who has 
had easy labors, when the pelvis is roomy and the soft parts easily dila- 
table, when the pains are good, and when the chin is anterior. 

Internal rotation may be favored by the turning of the chin forward 
with the fingers during the pains. 

In posterior positions of the chin, or in anterior positions when any 
abnormal condition exists, interference is necessary. 

Different procedures are recommended. At first the patient should be 
anaesthetized and an effort made to bring about a vertex presentation by 
external manipulation through the anterior abdominal wall. But if this 
procedure fail, the following means may be tried. 

When the chin is posterior an attempt may be made, first of all, to 
restore a vertex presentation by pushing up the sinciput. When the 
chin is anterior this would only result in an occipito-posterior position, 
and, therefore, it is not to be recommended. If restoration is carried 
out and the vertex engages, the case may be left to nature; if engage- 
ment does not soon take place, forceps should be applied. 

If restoration of the vertex presentation be not possible or advisable, 
delivery by version may be employed. If version be impossible or 
dangerous, owing to the conditions present, forceps may be used in an- 
terior positions. This is a difficult and dangerous mode of treatment, 
and is only to be undertaken as a last resort. The grip of the blades 
is bad for the child, and also for the mother, on account of the width 
between them. When the chin is posterior they should not be used at 
all, because if the head passes the brim, it tends to move, so that the chin 
goes into the hollow of the sacrum. 

When delivery is impossible by these procedures, embryulcia is justi- 
fiable. 

When the head has passed the brim and tends to be delayed, in spite 
of the efforts to promote extension and internal rotation, there is always 
danger to the child from the tension on the vessels of the neck and from 
the pressure against them, endangering the cerebral circulation. In such 
a case forceps should be employed. They must be used carefully, as 



ANOMALIES OF THE FCETUS. 469 

there is great risk that the blades may press dangerously on the nerves 
and vessels of the neck. 

When the chin has rotated into the hollow of the sacrum, efforts should 
be made to rotate it to the front, the patient being anaesthetized, if 
necessary. If this is impossible, the usual plan is to attempt delivery 
with forceps. When the head is passing the perineum the latter should 
be incised on each side to lessen the risk of bad laceration, and the 
patient should be in Walcher's position. As soon as the chin is born 
the rest of the head should be brought out by flexion. If this method 
of delivery be impossible, or if the child be dead, embryulcia may be 
performed'. Recently, however, owing to the success of symphyseotomy, 
it is strongly recommended that in a persistent occipito-posterior case 
this operation should be performed before delivery is attempted with 
forceps. There is far greater chance of getting a living child, and the 
risk to the mother is not much increased. 

Brow Presentations. 

Frequency. Brow presentations are very much less frequent than 
face cases. They are only a half-way stage in the development of the 
latter, the head being only partially extended. The most frequent posi- 
tion is that in which a vertex L. O. A. has been changed; the next most 
frequent that in which a vertex R. O. P. has been altered. 

Etiology. The causes are the same as in the case of face presenta- 
tions. 

Diagnosis. By external examination the condition cannot be made 
out. When labor has begun and the fingers can be passed within the 
cervix, the root of the nose, the margins of the orbits, and, possibly, the 
anterior fontanelle, may be felt. 

Mechanism of Labor. 1. In certain cases where the child's head 
is rather small a special mechanism may take place. The head passes 
through the brim in the extended position, the occipito-mental diameter 
having been diminished in length. The brow descending to the pelvic 
floor is then rotated to the front until it lies opposite the vulva, the face 
being behind the pubes and the chin at its upper margin; the occiput 
lies in the hollow of the sacrum. Flexion then occurs, the cranial vault 
sweeping over the perineum; the nose, mouth, and chin afterward pass- 
ing under the symphysis. The body is then born, rotation taking place 
for the delivery of the shoulders. 

2. Sometimes, when the pelvis is very large or the child small, the 
latter may be pushed through the pelvis without any mechanism. 

3. A natural change in the presentation may take place to a vertex or 
to a face. 

Head-moulding. After the mechanism described above, the head 
is characteristically altered. The caput succedaneum reaches from the 
root of the nose to the anterior fontanelle, the forehead is somewhat per- 
pendicular, and the parietal and occipital bones slope downward and 
backward. On profile the head has thus a somewhat triangular shape. 

In a case which has begun as a brow and finished as a face, the head 
is dolichocephalic, with a marked caput succedaneum on the forehead and 
one on the face. 




470 PATHOLOGY OF LABOR. 

Management. On diagnosing a brow case early in labor the sinci- 
put should always be pushed up, in order to bring about an engagement 
of the vertex, pressure being made during the pains. The case may 
then be left to nature, or forceps may be used. If the vertex presenta- 
tion cannot be produced successfully, and if the case be one in which 
the brow position is posterior (i.e., in which 
FlG - 302 - originally the occiput was to the front), delivery 

by version should be proceeded with. It is not 
wise to change the presentation to that of a face 
in this condition, because the chin will be made 
to lie posterior. If, however, the case be one 
in which the position is anterior, instead of per- 
forming version some prefer to bring about ex- 
tension to the head, and so to get a face presen- 
tation, the chin being to the front. The case 
may then be left to nature, or may be treated in 
the various methods recommended for face pre- 

Diagram showing head un- SentatlOllS. 

moulded and moulded by lahor When these procedures cannot be carried out, 
m a case of brow presentation. and ]&hor is flayed, it may be necessary to at- 
Red moulded. G tempt delivery with forceps, a procedure which 

is unfavorable both for child and mother. 
When this is impossible or too dangerous, embrylucia may be per- 
formed. 

Now, however, it is highly probable that symphyseotomy will displace 
both the use of forceps and embryulcia in these cases. 

When labor is delayed after the head has entered the pelvis, forceps 
is indicated. When mal rotation has occurred and the chin is posterior, 
the use of forceps is difficult and dangerous, and the case must be treated 
practically as one of persistent mento-posterior face. 

Pelvic Pkesentations. 

Fkeqtiency. According to the statistics of Pinard, pelvic presenta- 
tions occur in the proportion of one in thirty labors; excluding miscar- 
riages and premature births, however, he finds it to be about one in sixty. 
In the majority of cases the breech presents; in the rest either the knees 
or the feet present. 

The positions in order of frequency are : 

Left sacro-anterior, L. S. A. 
Right sacro-posterior, R. S. P. 
Right sacro-anterior, R. S. A. 
Left sacro-posterior, L. S. P. 
The denominator is the sacrum. 1 

Etiology. The conditions favoring a pelvic presentation are exces- 
sive liquor amnii, lax uterine and abdominal walls, obliquity of the 
uterus, multiparity, multiple pregnancy, monstrosity, death or prema- 

1 Berry Hart objects, riehtly, to the use of the sacrum as the denominator. We do not follow the 
sacrum in the mechanism of labor, but the hip which is nearest the front. Therefore, to keep up 
uniformity of description in the various mechanisms, he desires to denominate the positions in refer- 
ence to the hip. 



AXOMALIES OF THE FOETUS. 



471 



turity of foetus, placenta previa, contracted pelvis, tumors of uterus or 
neighboring structures. 

Diagnosis. On abdominal examination, the head is felt in the upper 
part of the uterus. The foetal heart-sounds are heard above the level 
of the umbilicus. 

On vaginal examination, early in labor, the hardness of the head is 
missed through the fornices. After labor has advanced the examining 
lingers may recognize through the cervix, the sacrum, coccyx, and ischial 
tuberosities. The anus is felt as a dimple below the skin level. If the 
child is dead, however, it may be gaping and may project as an eminence. 



Fig. 303. 



Fig. 304. 





Breech presentation. Right sacroposterior. 
Feet and cord in relation to os internum. (After 
A. R. Simpson.) 



Pelvic presentation. Left sacro-anterior 
position. (After A. R. Simpson.) 



If the child be a male the penis and scrotum may be felt; the latter 
should not be mistaken for the bag of membranes. The finger should 
be passed into the groin, which is distinguished from the axilla by the 
absence of ribs. Movements of the feet are felt when the case is a foot- 
ling presentation. The foot must be distinguished from the hand by the 
presence of the projecting heel and by the parallel toes. 

The feet usually lie close together. The knee is distinguished from 
the elbow by the presence of the patella, by its larger size, and by the 
absence of the sharp olecranon. 

Meconium may be distinguished in the vaginal discharge. It is abun- 
dant and tarry, not in flakes. 



472 



PATHOLOGY OF LABOR. 



A breech may be mistaken for a face (see page 466). 

Prognosis. In cases which are uncomplicated the maternal risks are 
no greater than in vertex cases. The risks are those of interference. 
They are laceration of the cervix and perineum, inertia of the uterus 
from too rapid delivery or from loss of blood, separation of placenta 
from too rapid delivery. 

The risks to the child are great, the mortality being about 1 in 10. 
These are due to prolapse of the cord and pressure on it; early escape 
of the liquor amnii, which is apt to occur, because the girdle of contact 
does not grasp the breech as well as it does the head, and, the forewaters 
not being completely shut off from the rest of the liquor amnii, the mem- 
branes burst under an abnormal degree of the force of uterine contrac- 
tion; partial or complete separation of the placenta from hurried delivery 
or prolonged compression of the placenta, leading to gradual asphyxia or 
to sudden death. Fractures and dislocations may be caused by interfer- 
ence. It is stated by Koettnitz that hematoma of the sterno-mastoid 
and torticollis are most frequent in connection with breech delivery. 

Mechanism. The normal mechanism usually takes place as follows : 
The breech is either pushed straight down through the pelvis, or the 



Fig. 305. 




Passage of buttocks over perineum m a breech case. (After Barnes.) 



anterior hip may descend somewhat in front of the other. This hip on 
reaching the sacral segment of the pelvic floor is rotated to the middle 
line in front, this movement being known as internal rotation. It 
becomes fixed at the pubic arch, while the trunk is more driven down 
into the pelvis and the posterior hip moves forward to the perineum, 
which gradually retracts over it. t The anterior hip is then somewhat 
released from being pressed against the pubic arch, and the whole pelvis 
moves onward, followed by the rest of the trunk, with the lower and 
upper extremities, both being in an attitude of flexion. Sometimes 
the lower limbs are not bent at the knees, but lie straight on the front 
of the body. This is less favorable, and may cause delay in labor, 
because the straight limbs act as splints, as Tarnier has stated, interfering 
with the flexing of the trunk and with its accommodation to the pelvic 
curve. The shoulders pass the brim, their long diameter in the trans- 
verse. The head passes flexed, its antero-posterior diameter lying in the 



ANOMALIES OF THE FCETUS. 473 

oblique or transverse of the brim. When it is well in the cavity rotation 
occurs, so that the occiput turns to the front, the face being in the sacral 
hollow. The face and the forehead are then born, followed by the rest 
of the head. 

Moulding of the Fcetus. The breech is swollen. It may be only 
(edematous, or may present a large, dark swelling. This is generally 
over the anterior hip, but it may spread to the region of the genitals, and 
may especially affect the scrotum in the male. These signs may also be 
found in the knees or feet when they present. 

Abnormalities in the Mechanism. 1. The breech may stick at 
the brim and may not engage. This is especially apt to be the case 
where the pelvis is contracted. 

2. Having entered the brim the body may stick, no further advance 
being made. This condition of matters may be due to the small size of 
the pelvis, abnormal size of the fcetus, contraction of the cervix, or to 
the extended position of the limbs on the anterior surface of the fcetus. 

3. The arms may be displaced upward, one or both being in front, 
behind, or at the sides of the head. This may be due to contraction 
of the cervix on the body above the pelvis of the foetus as it descends, 
or to the small size of the pelvis; but it is important to note that it 
may follow too hurrieB^emptying of the uterus when there is artificial 
delivery. Very often, when the lower limbs are displaced, the upper 
limbs are apt also to be displaced. 

This condition causes a delay in labor, which usually requires special 
treatment. The life of the child is endangered from the extra risk of 
pressure on the cord. 

4. The head may become impacted above the brim or in the pelvic 
cavity. This usually happens as a result of extension from too rapid 
delivery of the child. In other cases, where the pelvis is relatively 
large, and the sacrum directed toward the back, the anterior hip may 
not turn to the front, but the body of the fcetus passes straight through 
the pelvis, the shoulders passing the brim in relation with the transverse 
diameter. The head may descend and normal rotation of the occiput 
take place. But rotation may not occur, the occiput remaining in the 
hollow of the sacrum. 

In some of the cases in which the head gets extended at the brim the 
chin is apt to catch above the pubes and to delay labor. 

In cases, also, where the back of the foetus is to the front the head 
may stick above the brim if extension occurs. 

In the pelvis the head may also stick in the transverse from incom- 
plete rotation, or in the antero-posterior diameter, the occiput being to 
the front, owing to extension of the head having caused the chin to get 
fixed in the sacral hollow. 

General Management. No attempt should be made to alter the 
presentation, nor to interfere as long as labor progresses naturally. The 
physician should watch the case more closely than in a normal vertex 
case, and should have skilled assistance within easy reach. Dilatation of 
the cervix may be promoted by means of hot douches. But if the mem- 
branes have been driven down as a sausage-like pouch, or have ruptured 
early, Champetier de Ribes's or Barnes's bag may be used, and nature 
may be allowed to expel the pelvis and lower extremities. When the 



474 PATHOLOGY OF LABOR. 

umbilicus appears, a piece of cord is pulled dowu and examined. If it 
is pulsating well, nature may be allowed to continue the delivery. The 
exposed parts may be protected with a warm cloth and held up from the 
perineum. 

When the hands appear they may be freed. If it is found that pulsa- 
tion in the cord be feeble or has just ceased, it is necessary to hasten 
delivery. 

Fig. 306. 




Delivery of child In a breech case by pressure on fundus uteri and by traction on lower limbs. 

(After A. R. Simpson.) 

Another indication in the same direction is spasms of the body due to 
respiratory efforts. Speedy delivery is attained by suprapubic pressure 
on the uterus, accompanied with traction from below. Of very great im- 
portance is the former of these. The traction should be made in the 
axis of the pelvis, at first well backward against the perineum. 

Sometimes the cord passes between the legs of the child. In such a 
case a loop should be pulled down and slipped up over the posterior 
thigh. If this be impossible, or if the cord is wound around the body, 
it should be doubly ligatured and divided. Then delivery should be 
hastened. 

Management in Special Conditions. Non-engagement at the Brim. 
When the breech does not engage in the brim, a lower limb should be 
brought down, provided there be no undue contraction of the brim. The 
case may then be continued by nature; but if the patient be exhausted, 
slow artificial delivery should be carried on by means of pressure from 
above the pubes and by traction from below. The latter manoeuvre should 
be carried out as follows : The foot should be grasped between the first 
and second fingers. The other foot need not be brought down unless it 
is bent over the child's back or crosses the other leg. The limb should 
be drawn down slowly and by stages. When the leg is beyond the vulva 



ANOMALIES OF THE FOETUS. 



475 



it should be covered in a warm cloth and held by the whole hand. In 
pulling no marked friction against the pubic arch should occur. As the 
child descends it should be grasped close to the mother's vulva. When 
the breech reaches the perineum the traction should be more in the axis 
of the outlet. As the lower part of the abdomen appears the other leg 
usually falls out. The rest of the delivery should imitate the natural 
process. 

Fig. 307. 




Delivery ol child in a breech case by traction made with fingers placed in groin. 
(After A. R. Simpson.) 

Impaction of the Breech. When, having entered the pelvis, the breech 
sticks, various procedures may be adopted. Here it is impossible to pull 
down a limb safely. The index-fingers hooked into the groin may be 
sufficient to promote descent by traction. Better, however, is a fillet, 
such as a soft piece of silk cloth. An aseptic gum-elastic catheter 
threaded with a loop of string may be used to pass the fillet around the 
groin. A blunt hook is also sometimes used for the purpose of extrac- 
tion, but is apt to cause injury. The line of traction should be toward 
the side on which the sacrum lies, in order that fracture of the thigh may 
be avoided. 

Forceps may also be applied to the breech in such a case, though not 
without some difficulty. 

Sometimes delivery by these means is impossible, and embryulcia is 
necessary, a grip being obtained with a cranioclast, or crushing of the 
pelvis being performed with a cephalotribe. The after-coming head 
should also be perforated in such a case to render its passage more easy 
and to insure death of the child. 



476 



PATHOLOGY OF LABOR. 



Upward Displacement of the Arms, (a) When the head is still above 
the brim. When the brim does not allow the passage of the head and 
arms, jamming occurs just about the period when the tips of the scapulae 
appear at the vulva. It is then necessary to free the arms. The body 
of the foetus should be pushed a little upward in order to diminish the 
pressure on the arms at the brim, and the child's body should be rotated 
until its back is directed toward one or other side of the mother. It 
should then be pressed well forward against the symphysis, in order that 
an attempt may be made to free the arm which is most posterior. The 
hand is passed upward into the hollow of the sacrum and the first two 
fingers along the side of the neck behind the posterior arm as far as the 

Fig. 308. 




Method of freeing the anterior arm displaced upward in a breech delivery. 
(After A.. R. Simpson.) 

elbow. The latter should then be swept over the face and thorax until 
it comes to lie within the pelvic cavity. The body of the child is then 
pressed backward against the perineum, and an attempt made to bring 
down the anterior arm by a proceeding similar to that employed in the 
case of the other one. Sometimes it is impossible to get room enough 
to carry out this latter procedure. In such a case the body of the child 
should be carefully rotated by both hands placed on the thorax, the back 
of the child moving across the front of the mother's pelvis. The thorax 
should be well pushed up when this manoeuvre is begun, in order to 
diminish the risk of dislocating the neck. By this rotation of the back 



AXOJIALIES OF THE FCETUS. 



477 



of the child from one side of the mother's pelvis to the other, the arm 
which was anterior is made to lie posterior, and then it may be more 
easily drawn down. 

(6) When the head is below the brim. The release of the arms in 
this position is much easier than when placed above the brim. The pro- 
cedure is practically the same. The trunk should first be drawn down 
as far as possible. Usually the posterior arm is first brought down ; but 
the best rule is to release that one which is most accessible, the child's 
trunk being directed well toward the mother's pubes or perineum, as the 
case may be. 



Fig. 




Method of freeing the posterior arm displaced upward in a breech delivery. 
(After A. R. Simpson.) 



In some cases an arm gets jammed over the back of the head between 
the occiput and the pelvic wall. In freeing it the fingers should be 
passed up over the back of the foetus, and the arm carefully pushed 
around the side of the head to its own side. The elbow may then be 
drawn down over the face and thorax. Sometimes the arm in such a 
case may be released from its dorsal position by rotating the body in the 
opposite direction from that which caused the trouble. 

In all these manipulations on the arms there is danger of dislocating 
the shoulder-joint, of separating the epiphysis at the upper end of the 
humerus, of fracturing the humerus, clavicle, or spine of the scapula, 
or of injuring nerves. The traction should, therefore, be made in the 
bend of the elbow. 

In cases where this method fails, division of the clavicle may be per- 
formed — cleidotomy — to diminish the size of the shoulder-girdle. 

Constriction of the Head by the Uterus. Sometimes the retraction ring 
of the uterus may grasp the head tightly; sometimes the cervix may be 
closely retracted on the neck. This condition greatly endangers the life 



478 



PATHOLOGY OF LABOR. 



of the child, and delivery must be rapid. The patient should be deeply 
anaesthetized, and traction made on the shoulders and mouth, or forceps 
should be applied. 

Impaction of the Head. This may take place at the brim or in the 
pelvis. It may be due to the large size of the head or small size of the 
pelvis, or to some other form of obstruction. It may also be caused by 
the extension of the head when there is a want of suprapubic pressure. 
Generally, however, it is due to extension of the head, brought about by 
traction on the foetus unaccompanied with suprapubic pressure. 

The methods of delivery employed in these cases are : 

1. Manual Extraction, (a) By the Smellie Grasp. The body of 
the child is covered in a warm cloth and is placed on the flexor aspect 

of the physician's forearm, the legs hanging 
FlG - 31 °- down, one on each side. The fingers of this 

hand are passed into the vagina, the first and 
second fingers being placed in the fossae on 
j.-^g ;^7 each side of the child's nose. The fingers of 

the other hand are then passed up over the 
back as far as the occiput. By pulling down 
7^'- ''iWl^i with the fingers that are on the face, and 

'/// $Vv '''*m -M pushing up with those of the other hand, the 
head is flexed. Then, by raising the trunk, 
the head is born and the face is delivered 
over the perineum. 

(b) By the Prague Grasp. Some physicians 
prefer this grasp. One hand grasps the feet, 
by which the body can be drawn well back 
over the mother's perineum. The fingers of 
the other hand are hooked over the shoulders, 

>\iPHIl an( ^ then traction is made downward by both 

hands, the body being gradually carried to- 
ward the pubes as the face is drawn over the 
perineum. 

(c) Smellie -Veit or Mauriceau Method. 
This is the combined method of traction on 
the lower jaw and shoulders. The first two 
fingers of the hand that is in relation to the 
anterior aspect of the child are placed in the 
mouth, while the fingers of the other hand 
grasp the shoulders. The child is first drawn 
downward, and then the body is carried to- 

Prague grasp. ward the pubes, while the face sweeps over 

the perineum. 
Care must be taken not to fracture or dislocate the lower jaw. 
(d) Wigand-Martin Method. One hand is used with the fingers over 
the shoulders astride the neck to extract the child, while the other presses 
the head down from above the pubes. 

2. Forceps Extraction. "When the foregoing methods fail, forceps 
may be used. They are chiefly serviceable when the perineum is very 
rigid and when the head is arrested at the brim. In applying the blades 
the body of the foetus should be carried well against the pubes. When 




ANOMALIES OF THE FCETUS. 



479 



the occiput is to the back they will lie under the back of the child; when 
it is to the front they will lie under the abdomen. 



Fig. 311. 




The Smellie-Veit method of extracting the after-coming head. (D5deblein.) 



Fig. 312. 




The Wigand-Martin method of delivering the after-coming head. (Doderlein.) 



3. Delivery after Embryulcia. In cases in which the head 
cannot be delivered by any of the above methods, reduction of the head 
by perforatiou is necessary. This may be done through the skull or 
through the base of the mouth. 



480 



PATHOLOGY OF LABOR. 



Malrotation of the Head. Sometimes in the pelvis the head 
stays with its long diameter in the transverse, or with the occiput in the 
hollow of the sacrum. In these cases it is best to hold the head and 
trunk firmly by the Smellie grasp and to rotate them so that the occiput 
comes to the front, delivery being continued as already described. 

Transverse Presentations. 

Frequency. Various statistics are given, varying from 1 in 150 to 
1 in 300. It might be generally stated that less than \ per cent, of all 
cases of labor present transverse presentations. 

Causes. The causes are those of malpresentation in general — e. g., 
excess of liquor amnii; prematurity of labor; death of the foetus, by 
which its tone is lost; changes in the shape of the foetus by disease — e. g., 
hydrocephalus; malformations and monstrosities; multiple pregnancy; 
irregular contractions of the uterus; tumors of the uterus; tumors of 
parts near the uterus; uterine malformations; placenta prsevia. 

Fig. 313. 




Transverse presentation. Dorso-posterior, head on right side, arm prolapsed. (Faeabeuf.) 

Varieties. Any part of the body of the foetus may present; usually 
it is the shoulder, sometimes the hand or elbow, rarely the trunk. The 
long axis of the trunk is very rarely transverse; it is usually obliquely 
placed in relation to the long axis of the uterus. 



ANOMALIES OF THE FCETUS. 



481 



Positions. Attention need be paid only to the shoulder cases. The 
nomenclature employed differs in different countries. By some the acro- 
mion process is used as the denominator, by others the spine of the 
scapula. Certain writers prefer to make use of no denominator what- 
ever. It is, indeed, quite sufficient to classify the positions as follows : 
Dorso-anterior : 

Head on the right side. 
Head on the left. 
Dorso-posterior : 

Head on the right side. 
Head on the left. 
The dorso-anterior position, the head being on the left side of the 
mother, is the most frequent, and to it we will particularly allude in 
describing the mechanism of labor. 

Diagnosis. External abdominal examination reveals the unusual 
shape of the abdomen. The normal regular prominence of vertex and 



Fig. 314. 




Transverse presentation. Dorso-anterior, head on left side, arm prolapsed. (Farabeuf.) 



breech cases is absent. The regular pyriform shape of the uterus is 
wanting. It is felt to be moulded somewhat obliquely or transversely 
by the foetus. The head lies usually in an iliac fossa. The back is made 
out if it be to the front, or the irregularities of the limbs if they are 

31 



482 PATHOLOGY OF LABOR. 

anterior. The foetal heart-sounds are heard below the umbilicus in a 
dorso-anterior position, being conducted along the back of the foetus. 

If labor has been delayed and the uterus has been active, there may 
be an abnormal thinning and stretching of the lower uterine segment, so 
that the foetal parts may be felt very distinctly just above the symphysis; 
and, higher up, the thickness of the retraction ring, where the lower 
uterine segment of the body of the uterus joins the upper, may be made 
out. 

On vaginal examination early in labor the presenting part is usually 
very high, the vaginal fornix being somewhat flattened. The lower 
uterine segment is imperfectly filled, and the cervix may be felt hanging 
loosely. As labor proceeds the bag of membranes tends to protrude into 
the vagina in a sausage form and to be ineffective as a dilator. It tends to 
rupture early, and the cord also tends to prolapse. When the fingers can 
be passed into the cervix the shoulder may be recognized by the three 
bony ridges, clavicle, humerus, and spine of scapula running toward a 
central spot. A finger may be passed into the axilla, and the ribs felt, 
thus distinguishing it from the groin. 

Sometimes the elbows or hand may be distinguished. The diagnosis 
of these from knee and foot is given on page 454. To know which hand 
is prolapsed, it is best to shake hands with it, and thus to identify it. 

Prognosis. In cases left to nature the risk both to mother and child 
is very great. The risk may be increased by the causes of the malpre- 
sentation. As artificial delivery is now the rule in these cases, the prog- 
nosis is modified by and dependent upon the nature of the operative 
interference. The longer labor is allowed to proceed before treatment is 
carried out, the greater is the danger to the mother. 

The chief risks to the mother are exhaustion, rupture of the uterus, 
the results of operative interference, and after-inflammation. AVe have 
already referred to the great thinning and stretching of the lower uterine 
segment in a delayed transverse case; it is this part which is most apt to 
be ruptured. 

Methods of Spontaneous Delivery. 1. Spontaneous Version. 
This is the change by which nature alters the presentation from the 
transverse to that of the head or breech, the delivery then taking place 
according to the new presentation. This is most apt to occur in multi- 
parse whose uterine walls are lax. It is more apt to occur in the case of 
a living than of a dead child. 

This version may occur before the membranes have ruptured as well 
as afterward. In the former case the pains may be weak. In the case of 
version after the membranes have ruptured, the amniotic fluid having 
partly or wholly escaped, the presenting part must be movable and not 
jammed in the cervix or brim, and the uterine pains must be strong. 
As the uterus contracts on the foetus it is driven against the cervix, which 
is only partly dilated, firm, and resistant. The presenting part is grad- 
ually displaced to one side, and this is continued until version is partly 
or wholly completed. 

(It is interesting to note that occasionally, if left to nature, a complete 
rotation may be carried out, one transverse presentation being substituted 
for another. This only takes place w 7 hen there is a small child and 
plenty of liquor amnii.) 



ANOMALIES OF THE FOETUS. 



483 



2. Spontaneous Evolution, (a) Most common variety (Douglas). The 
delivery in this variety is by a special mechanism. Certain conditions 
are favorable to its successful progress. The pains must be strong, the 
pelvis roomy, and the foetus small. Softness and compressibility of the 
foetus are particularly likely to favor this mechanism. There is no doubt, 
however, that it may take place where the foetus and pelvis are of normal 
size. Very stroug pains are the chief essential. 

First of all, the foetus is packed into the brim, the presenting shoulder 
being forced downward to the pelvic floor, and rotated forward until 
it rests under the pubic arch, where it sticks, the corresponding arm 
usually hanging outside the vulva. At this period the foetus is so lateri- 
flexed that the head is above the brim, lying alongside the breech, the 
latter being posterior. The chest is now driven down past the shoulder, 



Fig. 315. 



Fig. 316. 




Spontaneous evolution. First stage. 



Spontaneous evolution. Second stage. 



then the abdomen and lower limbs, the presenting shoulder all this time 
pivoting on the pubic arch. Finally the head enters the pelvis and 
rotates, so that the occiput passes under the symphysis as its delivery is 
completed. 

(6) Rare variety (Roderer, Kleinwachter). In this form the body is 
delivered with doubled body (evolutio conduplicato cor pore). The condi- 
tions which favor it are compressibility of the foetus, small size of the 
foetus, and a large pelvis. When the foetus is dead, therefore, it can the 
more easily occur. 

The presenting shoulder is pushed down into the pelvis, the head also 
being crowded into it along with the body. The arm belonging to the 
lowermost shoulder protrudes from the vulva; the other one lies between 
the breech and the head. The mass thus doubled is driven down, the 
presenting shoulder being delivered first, then head and chest together, 
and, finally, the breech and legs. 



484 



PATHOLOGY OF LABOR. 



Management. Transverse cases should not be left to nature. Arti- 
ficial delivery must be carried out. If the condition be diagnosed before 



Fig. 317. 




Spontaneous evolution. Third stage. 
Fig. 318. 




Spontaneous evolution. Fourth stage. 

the membranes are ruptured or the presenting part jammed at the brim, 
version should be performed. The bipolar or Braxton Hicks' s method 



ANOMALIES OF THE FCETUS. 



485 



Fig. 319. 




Spontaneous evolution. Fifth stage. 



Fig. 320, 




Birth of child doubled 

corpore. (Kleinwachter.) 



should be adopted when, the cervix 
is only partly dilated, the vertex or 
breech being made to present. If 
it is a shoulder case, it is best to try 
to bring about a vertex presentation 
unless the pelvis be flat, in which 
case a breech presentation is best. 

If the abdomen presents, a pelvic 
presentation should be induced. 

At first external manipulations 
through the abdominal wall should 
be tried, in order to turn the foetus, 
anaesthesia being employed. If this 
method fail, other measures must be 
carried out. 

When the cervix is well dilated 
the bipolar method may also be 
adopted if the liquor amnii is still 
in utero. When it has escaped, in- 
ternal or podalic version must alone 
be tried; before the rupture of the 
membranes this method may also be 
employed, the membranes being rup- 
tured artificially. 

How long after the escape of the 
liquor amnii it is feasible to perform 
podalic version, cannot be definitely 
stated. Different authorities give 
different limits. The student should 
bear in mind that the nearer to the 
time of rupture, the easier and safer 
Evomtio condupiicato j s the p roce( Jure. It should never be 



486 PATHOLOGY OF LABOR. 

carried out when the uterus is firmly contracted on the foetus, or when 
the latter is jammed into the inlet. There is always risk of rupturing 
the uterus. The patient should always be deeply anaesthetized in per- 
forming internal version. 

In transverse cases where turning is impracticable, the child must be 
broken up by one or other of the following methods : 

Decapitation may be carried out, when the neck is accessible, by a 
blunt, a serrated, or a sharp hook. The body may then be extracted, 
and afterward the head. 

Evisceration, or removal of the contents of the abdomen and thorax, is 
recommended by some. This is not, however, a satisfactory procedure. 

Spondylotomy, dividing the spinal column with scissors, or spondylo- 
lysis, breaking it up with a basilyst, is a better means of reducing the 
size of the child before extraction. 

Prolapse of the Limbs. 

(a) In Head Presentations. 1. One or both arms may be prolapsed in 
front, behind, or at the sides of the head. When one arm prolapses it 
usually lies close to the temporal region. The worst form is that in which 
the arm is across the back of the neck. Sometimes the arms are folded 
under the chin, bringing about a brow or face presentation (q. v.). 

Treatment. If the condition be diagnosed before rapture of the 
membranes, nothing should be done until the cervix is completely dilated. 
Then the hand may be pushed up to allow the head alone to engage in 
the brim. If this fail, forceps may be applied to the head if there be no 
risk of catching the arm, or version may be carried out. In extracting 
with forceps the arm may slip up. When the case is made out only 
after the arm is well engaged in the brim, the head should be delivered 
with forceps. 

2. A foot may present with the head. The line of treatment is the 
same. Embryulcia may sometimes be necessary. 

(b) In Breech Presentations. Sometimes the hand presents. Nothing 
need be done. The hand may or may not slip up. 

(c) In Transverse Presentations. If a foot presents, the condition is 
not unfavorable, for as version is the usual treatment, it can be carried 
out more easily. If an arm presents, it may interfere with the entrance 
of the physician's hand prior to the performance of podalic version. 
Sometimes it may be pushed up out of the way while the operator's hand 
is being introduced. Generally it is advisable to fasten a piece of tape 
around the prolapsed wrist, so that it may be drawn out of the way and 
prevented from ascending during the delivery of the thorax. 

Anomalies of Foetal Development. 

Shortness of the Cord. This may be "absolute" when the cord has 
only a length of a few inches, or " accidental" when the length is 
reduced by coiling around the neck, body, or limbs. The latter is more 
frequently a cause of delay in labor. Sometimes the placenta may be 
detached in this condition; sometimes the cord ruptures, or is so com- 
pressed as to lead to the death of the child. Most umbilical cords break 



ANOMALIES OF THE FCETUS. 487 

under a weight of 8 J pounds; some resist as much as 15 pounds; others 
will not sustain 6 pounds. 

It is difficult to state what actually constitutes a short cord. It varies 
with the amount of stretching it will bear, with the place of attachment 
to the placenta, with the site of the placenta, and with the tightness of 
the coils. 

The Diagnosis of this condition is not easy. Sometimes there is 
marked pain at the placental site during contractions, marked recession 
of the head between pains, delayed labor, and occasionally irregular foetal 
heart-action. 

When the cord encircles the foetus and the latter is driven down, it 
rotates partly with the pains to undo the coiling, and so to relieve tension. 

The Treatment consists in freeing the coils, where it is possible, or 
in dividing the cord and delivering by forceps. If the cord cannot be 
ligated, two artery forceps may be attached to it, and it may be divided 
between them. Where these procedures cannot be carried out forceps 
should be applied if the head presents, and labor should be hastened if 
it be a breech case. 

Unduly Ossified Skull. The skull bones may be prematurely or abnorm- 
ally ossified, the sutures and fontanelles being partly or wholly closed. 
The head fails to undergo moulding in labor and delay results; it may 
be arrested in the brim or pelvic cavity. 

The application of forceps, symphyseotomy, or embryulcia may be 
necessary to delivery. 

Large Size of the Foetus. In the case of a large child — e. g., eleven 
pounds or more, there may be delayed labor. There are records of chil- 
dren delivered weighing more than twenty pounds. The causes are not 
definitely known. It is thought that multiparity, large size or advanced 
age of one or both parents, and unusual extension of the period of preg- 
nancy are related to its occurrence. 

The mechanism of labor by which the head attempts to pass through 
the pelvis is like that which takes place in a justo-minor pelvis, viz., by 
extreme flexion. The head becomes greatly moulded. Cephalhematoma 
may be produced. 

Treatment. In cases which are not very marked, extraction may 
be carried out with forceps. In very marked cases, however, this is 
useless, and may lead to bad lacerations. Pinard's rule is a good one, 
viz., never to overcome bony resistance by forceps-traction. Embryulcia 
or symphyseotomy is then necessary. 

Death of the Fcetus. 

When a foetus dies in utcro decomposition changes may cause disten- 
tion of its tissues with gas, and this condition, known as emphysema, may 
delay labor. In such a case it may be necessary to puncture the abdo- 
men, or any part distended, to allow the gas to escape. Eigor mortis 
may sometimes take place in the body and interfere with its quick passage. 

It is to be remembered that absorption from a decomposing foetus may 
hurt the mother. 



488 



PATHOLOGY OF LABOR. 



Enlargement of Head or Body by Disease. 

Hydrocephalus. This coDdition causes delay and trouble in labor, 
varying according to the nature of the hydrocephalus. The head enlarges 
by an accumulation of serum in the ventricles of the brain, especially in 
the lateral ones. Sometimes a collection in the membranes covering the 

Fig. 321. 




Hydromeningocele. (After Herrgott.) 



brain, especially the subarachnoid space, may cause enlargement, and a 
projection may take place through the skull, known as hydromeningocele. 
In the former of these conditions, where the disease is not much devel- 
oped, the bones, fontanelles, and sutures may appear normal, with the 



Fig. 322. 




Encephalocele. (After Vrolik.) 



exception that the bones are thinned, the brain being well formed, but 
large. In more marked cases the ventricles are enlarged, the brain- 
convolutions somewhat obliterated, and the bones of the cranium sepa- 
rated from one another and thinned. The forehead is increased in size 
relative to the face, the frontal bones bulge, and the superciliary ridges 



ANOMALIES OF THE FCETUS. 



489 



are prominent. In the most extreme degree the head is very large, 
being mainly membranous, the brain being represented only by a thin 
sac, and by traces of cerebral tissue at the base. Sometimes hydroen- 
cephalocele is formed during the course of enlargement, owing to the 
extension outward, between a deficiency of bone, of the skull contents. 

Spina bifida, or some other malformation, may also occur. Sometimes 
the large sac ruptures, the membranes collapsing and becoming attached 
to the brain structures at the base of the skull (anencephalus or herni- 
cephalus). Hydramnios may be present. Breech presentation is freouent. 





Puncture of spinal canal in a case of hydrocephalus obstructing labor. (After Herrgott.) 

Diagnosis. On abdominal palpation, where the head is distinctly 
enlarged, it may be easily felt. When the breech presents the head is 
found at the fundus uteri. The abdomen may be abnormally distended. 
Per vaginam, during labor, the wide fontanelles and sutures may be felt. 
Thin parchment-like bones may be distinguished, or a membranous con- 
dition of the vertex may be felt — a fluctuating sac becoming tense 
during the pains. Or islands of bone may be distinguished in the mem- 
brane. Sometimes a hydrocephalus may be present, but the bones may 
be firm and the sutures more or less ossified ; in this case it may be more 
difficult to establish a clear diagnosis unless the head is considerably 
enlarged. 

Prognosis. This varies according to the degree and extent of the 



490 



PATHOLOGY OF LABOR. 



disease and the nature of the treatment which is employed. The longer 
the delay the greater the risk. Death of the mother may occur from 
exhaustion or from rupture of the uterus. Rupture generally occurs in 
the lower uterine segment, which becomes greatly stretched and thinned; 
but it may take place higher up. Vesico-vaginal fistula may result from 
long-continued pressure. The child very often dies. 

Relation to Labor. Sometimes there may be little delay even 
when the head is large. This is due to softness and compressibility of 
the skull, especially when somewhat macerated or when it is mainly mem- 
branous, and to rupture of the membranous cranial sac. The latter occur- 
rence is most apt to take place when the breech presents. Delay may 
occur at the brim or in the cavity. 



Fig. 324. 




Exomphalos. (After A. R. Simpson.) 

Treatment. Little value need be attached to the life of the child. 
If it does not die in utero, it usually dies soon after birth. 

When the head presents it should be perforated and drained with a 
trocar. When the head collapses, delivery may be effected either by 
version or by embryulcia if the former method be inadvisable. 

If the foetus presents by the breech, either the head may be perforated 
behind the ear, as it lies at the brim, or Tarnier's method may be adopted, 
viz., to open the spinal canal and draw off the fluid by an elastic catheter 
passed through the spinal canal into the head. 



AS03IALIES OF THE FCETUS. 



491 



In the cases where the skull is enlarged, the bones still firm, and the 
sutures possibly ossified, it is usually necessary to perform embryulcia. 

Hydrothorax may cause trouble; it is generally associated with ascites, 
anasarca, or other conditions. It may obstruct labor, usually when the 
head has passed the brim. It may be necessary to puncture the thorax 
and extract with a cranioclast, reducing the size of the head, if neces- 
sary. Pericardial effusion may sometimes be very great. 

Ascites is sometimes met with, and is due to various conditions — e. g., 
abdominal tumors, syphilis. It may be a cause of obstruction, and in some 
cases a very marked one. As soon as the condition is diagnosed the size 
of the swelling should be reduced. This may be carried out by direct 
puncture of the abdomen. But it may be necessary to reach this part 
through the thorax. If a large tumor exists, it may be necessary to 
break it up or remove it. 

Fig. 325. 




Sacral tumor. (Keller: Mutter Museum, College of Physicians.) 



Distention of the Ureters and Hydronephrosis are rare. 

Dilatation of the Bladder. This condition is occasionally found. The 
urethra may or may not be imperforate. The foetus is rarely born alive, 
or, if living, soon afterward dies. It may sometimes be associated with 
ascites. 

Dilatation of the Uterus, the cervix being closed, is very rarely found. 

General (Edema of the body is occasionally met with. 

Abdominal Intrafcetation has been reported. In this condition the abdo- 
men contains another foetus, or part of one, which causes enlargement. 



492 



PATHOLOGY OF LABOR. 



Umbilical Hernia, or hernia through some other part, may lead to ob- 
struction! in labor. 

Exomphalos may cause delay. 

Tumors of the iiver, kidney, spleen, pancreas, and other viscera, some- 
times occur. 

Hydrorrhacis. This usually occurs with spina bifida. It is a collection 
of fluid in a sac composed of the spinal membranes and skin, and is 
usually in the coccygeal or sciatic region. The swelling varies; it may 
be very large. 

Fig. 326. Fig. 327. 





Congenital elephantiasis. (After Steinwirker.) 



OZdema of foetus. (After Betschler.) 



Tumors of various kinds, simple or malignant, may obstruct delivery — 
e.g., cystic, vascular, fatty, cartilaginous, bony, sarcomatous, carcinom- 
atous, teratomatous. Most frequently they are found in the region of 
the sacrum and coccyx — e. g., cystic hygroma. The neck is also an occa- 
sional seat of a growth. They are, however, found in every region of 
the body. 

Treatment. The general treatment for these conditions is as fol- 
lows : When the swelling is only slight, delivery may be effected by 
forceps or version; if the breech present, by traction and pressure from 
above. 

If too large for delivery, puncture of the swelling or reduction by 
embryulcia and evisceration are necessary. Thus, if, in a head presen- 
tation, the abdominal swelling cannot be reached without opening the 
thorax, the latter procedure should be carried out. It may even be 
necessary to reduce the head in size or to amputate it in order to get 
room. Sometimes the swelling bursts of itself. 

The following very rare conditions sometimes cause obstruction, viz., 
anchylosis of joints, adhesions of limbs to the body, anchylosis of foetus 
to placenta or uterus. 



ANOMALIES OF THE FCETUS. 493 

Plural Births. 

Twins. Relation to Labor. In a large percentage of eases twin 
labors are easy and uncomplicated. After the birth of the first child the 
second follows, there being an interval between, usually of less than an 
hour in extent, though it may be longer. Several cases have been 
reported in which the second child was born a day or two after the birth 
of the first. Kalriikoff has described one in which there was an interval 
of three days, both twins surviving ; both placenta? were removed at the 
second delivery. The placentae are generally delivered after the second 
child. Sometimes the first child may be followed by its own placenta. 
Sometimes the second placenta precedes the second child. Where the 
placenta is a large single one, it follows the birth of both foetuses, though 
sometimes a portion may be torn off and expelled with the first child. 

The following percentages are given by Spiegelberg to show the rela- 
tive frequency of the presentations met with : 

Both heads presenting, 49 per cent. 

Head and breech, 31.70 per cent. 

Both breech presentations, 8.60 per cent. 

Head and transverse, 6.18. 

Breech and transverse, 4.14 per cent. 

Both transverse, 0.35 per cent. 

The pains may be weak in twin cases, owing to the overstretching of 
the uterus, and there may be trouble in the third stage from this reason 
also. Hydramnios may be present. In some cases this may be found only 
in one amniotic cavity, oligohydramnios being the condition in the other. 

Prognosis. The mortality of the children is considerably greater 
than in single births. This is due to various causes. The labors are 
often premature and the foetuses, consequently, in an undeveloped state, 
one being usually weaker and smaller than the other. Malpresentations 
and malpositions are frequent, necessitating artificial delivery. The ma- 
ternal risk is also considerable. This is due to the delay which is often 
present as a result of weak pains; albuminuria is often found; eclamp- 
sia is more frequent than in single births; there may be trouble in the 
third stage from the large placenta, and from inertia uteri; post-partum 
hemorrhage may occur; there is a greater risk of septic absorption in 
the puerperium. If there is complete obstruction to the passage of the 
twins, the patient may die of exhaustion or of rupture of the uterus. 
Then there are risks attendant upon operative interference. 

Management of Labor. After the birth of the first child the cord 
must be tied in two places and divided, lest there be communication 
between the placental circulations and the second child should bleed to 
death. The uterus should then be gently kneaded through the abdom- 
inal wall to favor its retraction. There is a difference of opinion as to 
how long a time should elapse between the birth of the first and that of 
the second child. Our opinion is that it should not be prolonged, for, 
though the mother may gain strength, retraction and contraction of the 
cervix may occur. If the second child is transverse it should be turned. 
This may often be done by external manipulations. While the second 
child is being born a hand should be kept on the abdomen following the 
uterus. After this child is born the hand should hold the fundus uteri 



494 



PATHOLOGY OF LABOR. 



until the placenta is delivered. If there should be partial separation of 
the placenta and hemorrhage, the uterus should be emptied artificially. 
If there is inertia of the uterus, special care must be taken, according to 
the methods described on page 415. 

When the second child is discovered only after the birth of the first, 
the mother should not be informed, lest the shock should inhibit uterine 
action. 

If, after the birth of the first child, an hour elapses without the delivery 
of the second, the second bag of membranes, if there be one, should be 
ruptured, and the child delivered by version or forceps. 

In some cases it may be necessary to deliver the second child much 
earlier — e.g., if both placentae should be born before it, or if there should 
be much hemorrhage following the birth of the first child. 



Fig. 328. 




Locked twins. 



Complex Cases. 1. Sometimes labor may be delayed by the presence 
in the dilating cervix of two bags of membranes. When dilatation is 
complete the bag of the leading child should be ruptured. 

2. Where both presenting parts tend to enter the brim together, one 
should be pushed up to allow the other to engage. Where the head of 
one and the breech of the other are so placed, the head should be allowed 
to engage. 

3. Interlocking Twins. In some cases the twins may become locked. 
This may happen in two ways : 

(a) Where both heads present, the second may enter the pelvis after 
the first and jam against the neck or thorax. The heads must, of course, 
be small to permit this complication. 

Treatment. The most advanced head should be delivered with for- 
ceps, and then the other should be delivered. 

Sometimes embryulcia of one is necessary. This should be performed 



AXOMALIES OF THE FCETUS. 



495 



on the first child, because the second is more likely to be alive, there 
being less risk of compression of its cord. 

(6) In some cases where one child presents by the breech and the other 
by the head, the former may be delivered as far as the neck, but no 
farther, because the head of the secoud child has locked with that of the 
first; this may take place by overlapping of the chins, or of the occipital 
regions, or the face of one may be pressed against the back of the neck 
of the other. This locking occurs in the pelvis. 

Treatment. Sometimes the head of the second child may be pushed 
up. If this is impossible, and nature cannot soon bring about delivery, 
the head of the second child may be delivered by forceps. If this is 
impossible, or if there is great difficulty in applying the blades, embry- 
ulcia should be performed on the head of the child which is dead. In 
almost every case this is the breech-first child. After the extraction of 
the mutilated child the other mav be delivered. 









Fig. 329. 










t\ 






i 






i 


\ 




:/ 


x y 




/ . 1 \ 
1 X, 










c 


I 

I 


) 


y 






\ : J 


\i 


i 

i 

\ 


j 














\ 




' 


(/} 





Prosopothoracopagus. 



4. Interlacing and Knotting of the Umbilical Cord. This may occur 
where there is only one amniotic sac. The cords may be twisted around 
one another in various ways, or even knotted. If this happens early in 
pregnancy there is great probability that death of one or both twins will 
occur and premature labor be induced. It may, however, be found at full 



496 PATHOLOGY OF LABOR. 

time. As labor proceeds one cord may drag on the other and imperil 
circulation. 

Treatment. If after delivery of the first child the condition is 
diagnosed, the second child should be delivered at once by version or 
turning. 

Fig. 330. 




Derodyme or derodidyme. (After Ahlfeld.) 

Triplets. The greater the number of foetuses the greater the tendency 
to prematurity of delivery. Consequently, the labors may sometimes be 
comparatively easy. Sometimes, however, they are considerably pro- 
longed. The first stage is usually longer than normal. 

Albuminuria is more frequent; also inertia uteri and hemorrhage during 
or after labor. In 458 triplet cases collected by Charbonnier there were 
254 head presentations, 117 breech, and 57 transverse. According to 
this author there is a very small percentage of cases in which malpre- 
sentation and malpositions have caused serious trouble. The third stage 
must be very carefully attended to. Generally the three foetuses precede 
the placentae. Sometimes, however, each is followed by its own. Some- 
times there are two foetuses, then one or two placentae, followed by the 
third foetus and its placenta. Sometimes one foetus and its placenta are 
first, then the other two and their placentae. 

Monstrosities. 

Anencephalus or Hemicephalus. In this form the neck is short and the 
shoulders may be very broad. 



AXOMALTES OF THE FCETUS. 



497 



Delay in labor is caused by the bad action of the deformed head as 
a dilator, by the breadth of the shoulders, or by the entrance into the 
brim of the small head along with other parts of the foetus. Turning 
should be employed if the case be diagnosed early enough. 

Acardiacus is another rare monstrosity which may interfere with labor. 

Double Monsters. These may be considered in three main groups: 

1. Those in which there is double formation in the upper part of the 
body — e. g., a two-headed monster. 

2. Those in which there is double formation of the lower part. 

3. Those in which there are two heads and two bodies: 
(a) Those in which the backs are united. 

(6) Those in which the bellies are united. 



Fig. 331. 




Ischiopage. 

Diagnosis. This may be very difficult during labor. It can be best 
arrived at when the hand is passed into the uterus. Double monsters 
are apt to be mistaken for twins. 

Relation to Labor. In many cases these monsters are delivered 
naturally, probably because the foetus is usually small. 

Lroff has recommended the following treatment : When both heads 
present, and are movable, one should be pushed up, in order to allow 
the other to engage. Turning may sometimes be tried in order to 
deliver the legs first. Forceps may be used to aid the advancing head. 
Sometimes embryotomy is necessary. 

32 



CHAPTER XXI. 

ANOMALIES ARISING FROM ACCIDENTS OR DISEASE. 

Prolapsus Funis. 

In this accident a loop of the umbilical cord slips down alongside the 
presenting part or in advance of it. As the labor progresses the dis- 
placed portion of the cord is exposed to strangulation by pressure between 
the presenting part and the walls of the birth-canal. Unrelieved, the 
complication, as a rule, results in the death of the foetus within a few 
moments by interruption of the foeto-placental circulation. In excep- 
tional instances the cord may escape injurious pressure and the child be 
born alive. This is possible when the pelvis is relatively roomy and the 
expulsion of the foetus is accomplished in one or two pains. Prolapse 
of the cord may take place before labor begins, but in the majority of 
cases it does not occur until the cervix is well dilated. Ordinarily the 
two halves of the prolapsed cord lie in apposition, but occasionally the 
presenting portion of the child may intervene. Thus in vertex presen- 
tation the loop may extend upon opposite sides of the head, and in 
shoulder or footling presentation may include an arm or a leg. The 
prolapse occurs most frequently at one side of the promontory, rarely 
along the lateral wall of the pelvis, and still more rarely near the 
median line in front. 

When the prolapse is within the bag of waters it is sometimes spoken 
of as a presentation of the funis. 

Frequency. The frequency of prolapsus funis as generally estimated 
is about 1 in 250 labors. According to Winckel, it happens once in 
from 65 to 500 cases. In a collective investigation by Churchill, pro- 
lapse of the cord was reported 852 times in 91,000 births, an average 
of 1 in 107 cases. The complication is met most frequently when an 
extremity presents, next in order of frequency in breech, and last in 
vertex presentations. 

Etiology. The essential cause of prolapse of the cord is failure of the 
presenting part of the foetus to fill completely and continuously the lower 
uterine segment. Conditions, then, which may give rise to this lack of 
close approximation are predisposing causes of prolapsus funis. They 
are : narrow pelvis, which may act not only by hindering the adaptation 
of the head to the passages, but by favoring the occurrence of malpres- 
entation ; uterine myomata ; diminished size and consequent mobility 
of the fetus, favoring malpresentation and malposition ; abnormal pres- 
entations, especially breech, shoulder, footling, and face presentations ; 
excess of liquor amnii, causing preternatural mobility of the foetus; low 
implantation of the placenta ; marginal insertion or excessive length of 
cord; twin pregnancy, multiparity, owing to relaxation of the abdomi- 
nal walls and to uterine obliquity, especially to pendulous abdomen. 

An important exciting cause is premature rupture of the membranes 



ANOMALIES ARISING FROM ACCIDENTS OR DISEASE. 499 

and the sudden escape of a large amount of amniotic fluid, particularly 
if the woman is in a standing or half-sitting posture when the rupture 
occurs : the escaping fluid may sweep out a loop of the cord in front of 
the presenting part of the child. Violent movements on the part of the 
mother favoring recession of the foetus from the lower uterine segment 
and the gravitation of the cord may be included among the possible 
factors in bringing about the displacement. Maladroit attempts at 
version are sometimes responsible for the prolapse. 

Diagnosis. The examination should be made between the pains. The 
condition can scarcely be recognized before the os has dilated if the 
membranes are still intact. It may rarely be possible, if the lower ute- 
rine segment is thin, to detect, with the examining finger at the utero- 
vaginal junction, the pulsation of the cord. It is distinguished from 
maternal pulse by the count. If the os is sufficiently dilated to admit 
the finger, the cord may be felt when it lies well down in the mem- 
branes. Yet it may escape detection, owing to the facility with which 
it recedes from the examining finger. When the foetus is dead, pulsa- 
tion is, of course, absent. The absence of pulsation, however, can be 
taken as evidence of foetal death only when persistent for ten or fifteen 
minutes. The funic pulse may be interrupted temporarily by compres- 
sion of the cord between the pelvic brim and the presenting part. Fin- 
gers and toes are distinguished from the cord by their anatomical char- 
acters. Foetal parts, too, will sometimes be drawn up when touched. 
The prolapsed cord should not be mistaken for intestine. The latter is 
recognized by the mesentery and by the absence of pulsation. It is 
larger than the cord and not so firm in consistence. After the mem- 
branes have ruptured and the cord protrudes into the vagina, or through 
the vulva, the diagnosis presents no difficulty. The presence or absence 
of pulsation should always be noted, to determine whether the child is 
living or not, since this question will obviously have an important bear- 
ing on the treatment. Should the displaced loop be caught between the 
presenting part and the sides of the pelvis, but fall no farther, the con- 
dition may escape detection and the child be asphyxiated before the 
cause is discovered. Winckel says that whetn he foetal heart-sounds 
grow continually feebler and no cause is apparent, prolapse of the funis 
should be suspected, and the physician should act accordingly. 

Prognosis. In general this complication of labor has, of itself alone, 
little influence upon the mother. The treatment necessitated in the 
interest of the child frequently subjects the woman to the risks of shock, 
hemorrhage, and sepsis usually attendant upon forced delivery. 

For the child the prognosis is exceedingly grave. More than half the 
children die of asphyxia. Churchill places the infant mortality at 53 per 
cent., Scanzoni at 58 per cent. Depaul, in 143 cases, had 96 deaths. The 
prognosis, however, must necessarily vary with the conditions of the 
case, such as the position and presentation of the foetus, the degree of 
displacement, the part of the pelvis at which it occurs, the size of the 
cord, and the duration of the prolapse. Prolapse of the cord in vertex 
and even in breech is more surely fatal to the foetus than in other pres- 
entations, since the presenting part more completely fills the pelvis and 
the cord is more certainly strangulated. The risk to the foetus is com- 
paratively small while the membranes are intact. The possibility of 



500 PATHOLOGY OF LA BOB. 

escaping injurious pressure is obviously greater when the cord lies in 
that part of the pelvis in which there is most room. The size of the 
cord has some influence, since the thicker the cord the greater the 
amount of Wharton's jelly and the consequent protection of the vessels. 
With primiparse, in whom the passages are more unyielding and the 
labor more prolonged, the foetal mortality is greater than with women 
who have borne children. 

Treatment. When the child is surely dead or non-viable, the reposi- 
tion of the cord is obviously not called for. 

Before Rupture of Membranes. When the child is living and the mem- 
branes are unruptured, the latter should, if possible, be preserved. It 
should be a general rule before rupturing the membrane in any case 
first to examine for possible prolapse of the cord. For reduction of the 
displacement while the bag of waters is still intact postural measures 
should be tried. Harm can seldom come to the foetus from the prolapse 
so long as the waters have not escaped. The woman is required to lie 
on the side opposite that on which the cord has come down. Gravity 
thus favors the return of the prolapsed loop. The reposition may be 
assisted, if need be, by gently pushing up the cord between the pains, 
with care to avoid breaking the membranes. 

Should this fail the woman may be placed in the knee-chest position. 
In this posture the inverted axis of the uterus is nearly vertical, and 
gravity acts at the greatest advantage. The Trendelenburg posture 
may serve as a convenient substitute for the latter position. While not 
so effectual as the knee-chest, it is more so than the lateral posture ; the 
inclination should be about 45 degrees. 

The foetal heart is to be listened for at short intervals. The cord 
once reposited, to prevent recurrence of the prolapse the presenting 
part should be crowded into the excavation and firmly held there till 
engaged. 

A fairly good Trendelenburg posture may be had by raising the foot 
of the bed or cot, slipping down in the bed being prevented by the help 
of assistants ; or a chair placed prone upon the bed may be utilized, the 
back being covered with a folded comfortable. 

After Rupture of the Membranes. If the foetal pulse can be felt, the 
cord should be replaced, if possible. If pulsation has ceased and the 
foetal heart is still beating, the presenting pole of the foetus should be 
pushed up and the cord reposited after pulsation returns. Two methods 
are available — the manual and the instrumental. Either is to be under- 
taken with the aid of posture and generally of anaesthesia. The knee- 
chest, the Trendelenburg, or even the lateral position, with the hips 
strongly elevated, may be chosen. The first is the most effectual, but is 
not always practicable, under anaesthesia, without the aid of skilled 
assistants. 

Manual Method. It must be remembered that much handling of 
the cord enfeebles the circulation and endangers the life of the child. 
The cord should be gently drawn to the front of the pelvis, where the 
reposition can most easily be effected. It is seldom that the prolapsed 
loops can be caught up in the hand and returned into the cavity of the 
uterus, or even pushed up inch by inch; as fast as one part is reposited 
another comes down. Yet success is sometimes possible by either of 



ANOMALIES ARISING FROM ACCIDENTS OR DISEASE. 501 

these plans. A method which has rarely failed in the writer's hands is 
this : The prolapsed loop is loosely twisted into a rope with great care to 
avoid interference with the circulation. It can then readily be replaced 
within the uterus. For retention, the woman may be kept in the latero- 
prone position, or the presenting pole be held in the brim till engaged. 
Occasional examinations are made per vaginam to make sure that the 
cord has not again slipped down. The foetal pulse-rate is listened for at 
frequent intervals. 

Instrumental Method. A suitable instrument for repositing the 
prolapsed cord may be improvised with a large English catheter and a 
lew feet of tape. A loop of the tape is made to encircle the cord loosely, 
and its free ends are attached to the tip of the catheter. The repositor, 
with a stylet inserted, is pushed into the uterus well up to the fundus, 
carrying the cord with it. The stylet is withdrawn and the catheter left 
to be expelled with the child. If preferred, the tape may be secured to 
the catheter by a bow-knot, which can be untied by pulling on the free 
end of the tape, and the cord thus be set free. The instrument may 
then be withdrawn. Return of the prolapse is prevented by pressure 
over the fundus, holding the presenting pole in the brim till firmly 
engaged. 

Version or Forceps. Attempts at reposition failing, if the child is still 
living, immediate resort should be had to version or forceps. It is some- 
times possible to save the child by rapid delivery without replacing the 
funis. The cord should first be disposed in front of that sacro-iliac joint 
opposite which there is most room. 

Inversion of the Uterus. 

Inversion of the uterus may be complete or partial. In complete 
inversion the organ is turned inside out and upside down. In partial 
inversion it presents a cup-shaped depression of greater or less depth at 
the fundus. 

Frequency. Fortunately this accident is exceedingly rare. Winckel 
had never seen a case of complete inversion of the uterus in 20,000 cases 
of labor, nor had Braun in 250,000. In 192,000 labors at the Rotunda 
Hospital in Dubliu, covering a period of nearly a century, one case was 
reported. The accident is doubtless more frequent in private than in 
hospital practice. Kehrer says it is believed to occur once in 2000 labors. 
Inversion of the uterus seldom takes place except at term, yet we have 
records of cases complicating miscarriage at six months, and Woodson 
reports a complete inversion following miscarriage at four months. 

Varieties. The inversion may be acute or chronic. The latter variety 
concerns the gynecologist rather than the obstetrician, and will not be 
discussed in this connection. Three degrees of acute inversion are recog- 
nized : 

1. A cup-shaped depression of the fundus, the latter approaching but 
not engaging in the os uteri. (Fig. 333.) 

2. Partial inversion, the fundus protruding from the os. This is a 
true intussusception. (Fig. 334.) 

3. Complete inversion (Fig. 335). In the latter variety, the uterus 
being turned inside out, the body of the organ may project from the 



502 



PATHOLOGY OF LABOR. 



vulva, appearing as a rounded mass between the patient's thighs. In 
the funnel-shaped depression formed by the inverted uterus may be 
found, in addition to the appendages, small intestine and a portion of 
the omentum. 

Etiology. Much discussion has arisen among writers as to the causes 
and mechanism of inversion of the uterus. One factor of paramount 
importance, and in the absence of which inversion is practically impos- 



Fjg. 332. 



FIG. 333. 





Beginning inversion of uterus, placenta 
attached. (Modified from Ribemont-Des- 
saignes and Lepage.) 



Cup-shaped depression of fundus. (Modi- 
fied from Ribemont-Dessaignes and Le- 



sible, is atony or paresis of the uterine muscle. In an exhaustive article 
on this subject Crampton arrives at the following conclusion: "Inver- 
sion of the uterus is preceded by paresis of some portion of the uterine 
muscle, not necessarily at the placental site, the main causes being too 
frequent child-bearing, tedious labors, precipitate labors, repeated miscar- 
riages, and traumatism.' ' For traction on the cord to produce inversion 
there must be some attendant paresis. In the absence of inertia the cord 
would break under the strain necessary to invert the uterus. Inversion 
may take place in sudden or unexpected delivery while the woman is 
in the standing position. The accident is most likely to occur either at 
the moment the child is born or during the third stage of labor. Inver- 
sion of the uterus may originate in any of the following ways : 

1. The inversion may be spontaneous. When the placental attach- 
ment is at the fundus a temporary atony of the uterine muscle at 
this point may cause a dipping down of the fundus, and the beginning 
inversion may be increased by the weight of the placenta if still attached, 



AXOMALIES ARISIXG FROM ACCIDENTS OR DISEASE. 



503 



and of the abdominal viscera pressing upon the fundus from above. 
(Fig. 332.) The inverted portion now acts as a foreign body, and being 
firmly grasped by the non-paralyzed segment of the uterus, it is carried 
further down at each contraction of the organ. A similar phenomenon 
is observed in intussusception of the bowels. Inversion arising in this 
manner is most likely to be incomplete. 

2. The accident may be caused by unskilful pressure of the obstetri- 
cian's hand on the fundus. Instances have been reported in which inver- 
sion of the uterus was produced by attempts at expressing the placenta 
directly after the completion of the second stage of labor. If, before 
sufficient time has elapsed for contraction to occur, forcible pressure be 



Fig. 334. 



Fig. 335. 





Partial inversion of uterus. (Modified from 
Ribemont-Dessaignes and Lepage.) 



Complete inversion of uterus. (Modified from 
Ribemont-Dessaignes and Lepage.) 



made on the fundus, inversion may result. Among the medical writings 
of the ancients mention is made of uterine inversion induced in this 
manner. 

3. A common cause is believed to be traction upon the cord in the 
endeavor to remove the placenta shortly after the child is born. The 
relaxation of the uterus usually present at this time favors the inversion. 
In exceptional instances of short cord the fundus may be dragged down 
by the tension put upon the cord as the child is expelled. 

Symptoms. The usual symptoms of inversion of the uterus are pain, 
hemorrhage, vesical and rectal tenesmus, and profound shock. The 
intensity of the symptoms, however, varies greatly in different cases. 



504 PATHOLOGY OF LABOR. 

Ordinarily the pain is severe. It comes on abruptly, and is referred to 
the lower abdomen and the pelvis. The abdomen is painful to the 
touch. The hemorrhage may or may not be profuse, depending upon 
the degree of uterine relaxation. In exceptional cases it is insig- 
niticant : generally it is excessive. In the latter event the symptoms 
of acute anaemia are present. 

The vesical and rectal symptoms are sometimes wholly absent. Occa- 
sionally there is retention of urine. Reeve reports two cases of complete 
inversion in which there was nothing in the patient's appearance or his- 
tory to excite suspicion of the accident. Jewett has published a similar 
case. 

Diagnosis. As a rule, the acuteness and severity of the symptoms are 
such that they can scarcely fail to arrest the physician's attention should 
he be present when the inversion occurs. The diagnosis, however, must 
rest mainly on the physical signs. These are essentially the absence of 
the usual abdominal tumor, the presence of an intravaginal tumor, and 
the character of the tumor. It is indispensable to a satisfactory physical 
examination that the bladder and the rectum be empty. If the examiner 
is expert, the absence of the uterus in the abdomen may be determined 
beyond all possibility of doubt by the combined abdominal and vaginal, 
followed, if necessary, by the abdomino-rectal examination. The pres- 
ence of the tumor in the vagina is obvious to the touch, sometimes to the 
eye. It must, however, be differentiated from a uterine polypus. The 
distinguishing points are the following: The inverted uterus presents a 
funnel-shaped depression at the cervix, which may generally be made 
out with one hand over the abdomen, the other making counter-pressure 
over the tumor within the vagina. If the inversion has existed for 
several days the abdomen may be too tense and too tender for satisfactory 
palpation ; but this difficulty may be overcome by anaesthesia. In uterine 
inversion the implantation of the pedicle is circular, while in a polypus it 
is lateral. In the latter condition a uterine sound may be passed by the 
side of the pedicle into the uterine cavity, while in the former the sound 
will be arrested at the root of the pedicle. Sometimes it is possible by 
inspection with the aid of the speculum to detect upon the surface of the 
tumor the openings of the Fallopian tubes. The special contractility of 
the uterus may aid in differentiating. The possible presence of the 
placenta still adherent to the uterus must be borne in mind. Distinction 
from a polypus, however, is sometimes difficult. 

Prognosis. Inversion of the uterus is among the most formidable com- 
plications of childbirth. Death may occur within a few hours from 
hemorrhage and shock, or later from septicaemia. Rarely a chronic 
inversion may exist for months or years. In exceptional instances spon- 
taneous reposition has taken place, and recovery has been known to fol- 
low the separation of the organ by sloughing. The total mortality may 
fairly be stated at from one-quarter to one-third. 

Treatment. Prophylaxis. Puerperal inversion of the uterus is gen- 
erally, if not always, a preventable accident. It is scarcely possible under 
a proper management of the third stage of labor. The prophylaxis con- 
sists in the avoidance of traction upon the cord while the uterus is 
relaxed, and of manipulation which may indent the fundus, and finally 
of properly directed efforts to bring about a prompt and persistent retrac- 



ANOMALIES ARISING FROM ACCIDENTS OR DISEASE. 505 

tiou of the uterus. If the uterus is intelligently watched, with the hand 
on the abdomen over the anterior surface of the fundus, from the moment 
the child is expelled till retraction is complete the slightest depression at 
the fundus may immediately be detected and reduced. Failure to con- 
tract normally can usually be corrected by friction or by compression 
with one or both hands. 

Reposition. There are three methods of employing taxis in the reduc- 
tion of a recent inversion of the uterus. The first consists in grasping the 
fundus of the uterus in the hollow of the right hand and making gentle 
but firm pressure upward in the axis of the pelvis. 

In the second method the hand is carried into the vagina with its back 
toward the uterus, and with the fingers a part of the lateral uterine wall 
is pushed upward through the constricting ring. With the fingers of 
the other hand applied over the abdomen the cervical ring is dilated. 
As the ring yields the lower uterine segment, and finally the entire body 
of the uterus, is pushed upward through the cervical girdle. Care 
should be taken to direct the pressure toward one side, in order to avoid 
the promontory of the sacrum. 

The third method consists in making alternating pressure at the 
middle of the fundus or near the orifices of the oviducts with the 
coned fingers. As a rule, the induction of the inversion by whatever 
method is to be undertaken only with the aid of an anaesthetic. 

Reposition being complete, the hand is kept within the uterus for 
several minutes till a contraction occurs. To excite uterine contraction 
and stop the bleeding, ergot or ergotine is administered subcutaneously. 
Putting the child to the breast may help, or an intra-uterine douche of 
sterilized water, at a temperature of 110°, may be given. Rarely will 
it be found necessary to tampon the uterus with iodoform gauze. 

Should the placenta be attached to the inverted uterus, it should gen- 
erally be separated before repositing, especially if it be partially detached. 
When inversion has existed for several days or more, attempts at reduc- 
tion may still be made, but with much less prospect of success than at 
the close of labor. In such cases, before taxis is tried, a rubber bag may 
be introduced into the vagina and distended with water. After eight or 
ten hours the bag is removed and taxis tried. 

The taxis may be repeated at intervals of six or eight hours, elastic 
pressure with a water-bag being maintained during the intervals. In 
difficult cases advantage may be taken of the knee-chest or the Tren- 
delenburg positions. It is scarcely necessary to say that all manipula- 
tion or instrumentation within the vagina must be conducted under a 
strict asepsis. Extreme measures must be avoided during the puerpe- 
rium, and attempts at reposition are best postponed for three or four 
weeks, should they not prove successful within twenty-four or forty-eight 
hours. 

If the uterus is infected, early amputation is generally advisable. 
But hysterectomy, together with the treatment of chronic inversion, 
belongs more properly to the province of the gynecologist. 



506 PATHOLOGY OF LABOR. 

Rupture of the Uterus. 

Rupture of the uterus may occur in any portion of the organ, and 
daring gestation, labor, or the puerperium. Laceration of the infra- 
vaginal portion of the cervix is an accident of little consequence; indeed, 
a tear of greater or less extent is apt to occur in all first labors. These 
lacerations are discussed elsewhere. Of an entirely different character 
are ruptures of the supravaginal portion of the cervix or of the body of 
the uterus. While spontaneous rupture of the uterus may take place in 
the later months of gestation or during the puerperal period, the vast 
majoritv of ruptures occur during the second stage of labor. In this con- 
nection will be discussed more especially ruptures of the body of the 
uterus occurring during childbirth. 

Frequency. Fortunately, uterine rupture is a rare accident. The fre- 
quencv may be stated at 1 in about 4000 labors. Churchill, however, 
gives the proportion as 1 in 1331, Bumm 1 in 940; and Jolly estimates, 
from nearly one million cases, that the accident occurs once in 3400 
labors. The latter authority found that in 573 cases of rupture of the 
uterus, 376 were spontaneous and 197 were traumatic. The percentage 
is large in countries where rachitis and osteomalacia are prevalent, 
pelvic deformity often being the predisposing cause of rupture of the 
uterus. 

From the extreme reluctance which practitioners naturally have for 
publishing cases of this unfortunate accident occurring in private prac- 
tice, estimates of its frequency must be derived mainly from the records 
of the large hospitals. 

Pathological Anatomy. While rupture of the uterus may involve any 
portion of the organ, it usually begins in the inferior segment. This is 
accounted for by the greater distention and consequent thinning to which 
this portion of the uterus is subjected during labor, especially in labors 
attended with violent uterine contractions. The anterior and the poste- 
rior wall of the lower uterine segment, too, are exposed to injury by 
pressure between the bony prominences of the sacrum behind, or of the 
symphysis in front, and the child's head. Sometimes the vaginal por- 
tion of the neck is torn away in the form of a ring before the advancing 
head. Most frequently the seat of rupture is lateral. When rupture 
occurs at or near term, and is due to external violence, the superior por- 
tion of the anterior wall is usually the location of the injury. When 
the uterus is the seat of a neoplasm, either benign or malignant, the elas- 
ticity of that portion of the organ which is diseased is diminished, and 
rupture may occur along the edge of the degenerated tissue. Some 
authorities hold, however, that this want of elasticity affords greater 
resistance to intra-uterine pressure, and that, consequently, when the 
uterus is ruptured, the portion involved in the new growth is the last to 
give way. 

The extent, direction, and shajDe of the tear are subject to the widest 
possible variation. The extent of the injury varies in different cases 
from a small rent scarcely large enough to admit the finger tip to a 
laceration permitting the escape of the child and placenta into the abdom- 
inal cavity. The direction is most frequently vertical, sometimes trans- 
verse or oblique. It may involve the entire length of the uterus; 



PLATE XXXII. 




Rupture of Fundus, with Total Escape of Foetus into Abdominal 
Cavity. Rupture also Near Cervix. 




■- c 

I - 



3£ 



3 O 
■K &3 

"/- - 



3 

7 2 



- - 



ANOMALIES AEISIXG FROM ACCIDENTS OR DISEASE. 507 

frequently it invades the vagina, and in exceptional instances the bladder. 
Jewett has reported two cases in which the child escaped into the 
peritoneal cavity through a rent, most of which was in the posterior 
vaginal wall. Transverse tears may extend through the circumference 
of the organ. Rarely the tear is even and clean cut. Usually the 
edge of the wound presents a jagged and irregular appearance, owing 
to the contractility of the muscular fibres of the uterus. 

If the patient survives the accident for forty-eight or seventy-two 
hours, there may be found post mortem a large quantity of blood in the 
abdominal cavity ; indeed, the hemorrhage is often the cause of death. 
The tissues around the margin of the wound are frequently swollen and 
ecehymosed, and there may be patches of necrotic tissue. Where the 
uterus was primarily the seat of lesions favoring rupture evidence to 
that effect will be observed. 

The rupture may be complete or partial. In complete rupture the tear 
involves both the muscularis and the peritoneum, opening the perito- 
neal cavity ; in incomplete rupture the laceration extends through the 
muscular wall only, the serous covering remaining intact. In complete 
rupture loops of intestine may prolapse into the uterus, and even into 
the vagina. Infective peritonitis rapidly follows the extrusion of the 
foetus and placenta into the peritoneum. The accident, it is scarcely 
necessary to say, is immediately fatal to the foetus. The laxity with 
which the peritoneum is attached to the inferior wall of the uterus 
makes it possible for a rupture beginning in the supravaginal portion 
of the neck to extend upward for a considerable distance in the muscular 
layer of the uterus without laceration of its serous covering. Most fre- 
quently the tear in the serous covering takes place at the insertion of the 
broad ligament. In subserous lacerations a large effusion of blood may 
accumulate at the seat of the rent without the peritoneal cavity. The 
peritoneal coat may be ruptured, the muscular layer remaining intact. 
This form of laceration is possible during either pregnancy or labor 
when from any cause elasticity of the peritoneum has been impaired. In 
these rare instances hemorrhage and diffuse peritonitis may result. 

Etiology. The causes of rupture of the uterus are: I. Predisposing 
and II. Determining. 

I. Predisposing Causes. During pregnancy and at term the uterus 
becomes greatly distended, and its walls are softened and thinned. Con- 
ditions which lead to excessive distention of the uterus are hydramnios, 
multiple pregnancy, hydrocephalus, and those which lessen the resistance 
of the uterine wall. Multiparity, late primiparity, or systemic disease 
may act as predisposing causes. According to the statistics collected by 
Brand, of 546 cases of rupture, only 64 occurred in primiparse. Since 
male children are ordinarily larger than female, sex, as suggested by 
Keever, may be a predisposing factor. He found that in twenty cases 
of rupture three-fourths were male children. 

The influence which some form of degeneration of the uterine wall may 
exert as a predisposing cause of rupture is undoubtedly great, though 
clinical evidence to this effect is necessarily meagre. Traumatism of 
various sorts, as blows, falls, kicks, etc., may weaken the wall of the 
uterus at the site of injury. The muscular fibres of the uterus may be 
the seat of degenerative changes, calcareous, fatty, or apoplectiform, con- 



508 



PATHOLOGY OF LABOR. 



ditions which favor rupture. The weak point may be in the scar left 
by a former Csesarean .section. Malignant disease of the uterus exposes 
to rupture. A large growth in the uterus, as a submucous fibroid, may 
by its mechanical presence offer an obstacle to the expulsion of the child, 
and thus favor rupture. Malformation of the uterus predisposes to this 
accident. Rarely the uterus is perforated in cystic degeneration of the 
chorion. Pelvic deformity is one of the commonest of the predisposing 
causes of uterine rupture. 

Other conditions which give rise to disproportion between the foetus 
and the birth-canal, or which obstruct the birth, as marked uterine 
obliquity, malpresentations, and malpositions, may predispose. While 
rupture of the uterus rarely occurs before the membranes have broken, 
a case is recorded by Hamilton in which at the autopsy the lateral Avail 
of the uterus was the seat of a tear of considerable extent, the membranes 
still being intact. Rupture of the puerperal uterus is due to sloughing 
or to a dissecting metritis. 

II. Determining Causes. The determining or exciting causes of 
rupture of the uterus may conveniently be grouped under two heads — 

Fig. 33f>. 



Contraction ring- 
Round ligament' 

Internal os. 
External os. 



Contraction ring 
Round ligament 




Arm presentation with threatened rupture of thinned iower segment of uterus. (Schroeder.) 

traumatism and excessive uterine contraction. Examples of the former 
class are blows, mils, and kicks. The prominence of the uterine tumor 
at term increases the risk from external violence to which persons in all 
walks of life are daily exposed. Rupture occurring from these causes 
concerns the general surgeon rather than the obstetrician. Of much 
more frequent occurrence is perforation by the hand or instruments, and 



I 

ANOMALIES ARISING FROM ACCIDENTS OR DISEASE. 509 

rupture from unskilful attempts at version, the high application of the 
forceps, prolonged attempts at separating a firmly adherent placenta, 
and other obstetric operations. Hess, from an extended experience, be- 
lieves that spontaneous rupture of the uterus is an accident of great 
rarity, whereas the lacerations produced by rough manipulations are 
comparatively common. Probably the most important element in deter- 
mining a rupture is excessive uterine retraction. The researches of 
Bandl, first published in 1875, have added much to our knowledge of 
this subject. He showed that the upper two-thirds only of the uterus is 
the contractile portion, the lower third taking no direct part in the 
expulsion of the foetus. As labor progresses the upper portion of the 
uterus becomes thicker with each contraction, while the lower portion 
grows thinner and more distended. At the junction of the upper and 
lower segments there is formed a well-marked line of demarcation, which 
occasionally can be felt through the abdominal wall, the " contraction- or 
retraction-ring." If during a pain the presenting part meets with 
obstruction, as in contracted pelvis, or a shoulder presentation, or pelvic 
tumor, the lower segment of the uterus becomes excessively thinned 
until finally, under the influence of an unusually forcible contraction, rupt- 
ure occurs. There can be no doubt that the injudicious exhibition of 
ergot has, not infrequently, been the cause of rupture. Meigs reports 
three cases, and Bedford four, traceable directly to this cause. Jolly 
collected thirty-three cases of uterine rupture in which ergot was given 
in large doses. In all cases of disproportion, whether referable to the 
foetus or to the birth-canal, rupture may be caused in one of two ways : 
either as the direct result of excessive and prolonged contractions, or in 
consequence of compression of the uterine wall between the presenting 
part and the bony pelvis. 

Diagnosis. In most cases of threatening rupture of the uterus certain 
premonitory symptoms may be observed. Excessive crampy pains in the 
lower abdomen may be felt, arising from overdistention or compression 
of the uterine wall. It is but reasonable to assume that when rupture is 
imminent the distress occasioned by undue stretching of the uterine walls 
will be greater and more persistent than in normal labor. Most signifi- 
cant of impending rupture is an abnormally high position of the retrac- 
tion-ring, felt near the line of the umbilicus. 

The occurrence of rupture of the uterus is made manifest by the fol- 
lowing usually characteristic phenomena : In course of some obstetric 
manipulation, or perhaps during a violent expulsive effort, the patient is 
suddenly seized with intense pain, differing entirely from a normal labor- 
pain ; this acute and cramp-like pain may be accompanied with a sound 
of tearing, audible in some cases to the bystanders as well as to the 
patient. The uterine contractions invariably cease, the patient complains 
of a dull continuous pain in the lower part of the abdomen, and the 
evidence of profound shock is quickly manifest. The face is pale, 
exhibits great suffering and apprehension, and becomes covered with a 
cold, clammy sweat ; the respirations are rapid and shallow ; the pulse 
small and imperceptible. Nausea, vomiting, and syncope frequently 
ensue. There is usually, but not always, some external hemorrhage. 
A physical examination reveals a change in the contour of the abdo- 
men, and marked tenderness at the seat of rupture. If the rent in the 



510 PATHOLOGY OF LABOR. 

uterus is large enough to permit the escape of the foetus into the perito- 
neal cavity, the foetal parts may be palpated through the abdominal wall, 
and apart from them may be felt the uterus, perhaps contracted down 
to the size of a foetal head. Foetal heart-sounds and active foetal move- 
ments are absent. Upon vaginal examination the presenting part will 
be found to have receded, or, possibly, some other portion of the child 
may be encountered, or a loop of intestine may be found prolapsed. If 
one or two lingers or the entire hand are introduced into the uterus, the 
site of the rupture may easily be detected, and the diagnosis confirmed. 
Some writers have called attention to the emphysematous condition of 
the abdominal walls arising from the entrance of air into the cellular 
tissue, and to a hypogastric tumor formed by the escaped blood. 

While the characteristic symptoms of rupture are usually present in 
exceptional cases, neither shock, external hemorrhage, cessation of the 
uterine contractions, nor marked local pain is present, and the true 
condition can be determined only at the autopsy. In this connection 
the following statistics from Jolly are of interest : Of 580 cases of rupt- 
ure the contractions ceased in 256 ; there was external hemorrhage 
in 148, collapse in 179, retraction of the presenting part in 146, and 
abdominal pain in 133. The foetal limbs could be felt through the 
abdominal wall in 77 cases. 

The practitioner will do well to view with suspicion any abnormal 
pain occurring during the second stage of labor, especially if accom- 
panied with shock. Reasonable suspicion of rupture calls for immediate 
extraction of foetus and placenta and a thorough exploration of the 
uterine wall with the hand in the uterus. 

Prognosis. In complete rupture of the uterus without radical treat- 
ment the prognosis is exceedingly grave. The outcome for the child is 
almost necessarily fatal, 92 per cent, of all cases resulting in the death 
of the foetus. The immediate cause of death is asphyxia. The mater- 
nal mortality is not so high : probably under the best modern treatment 
about 60 per cent, of the women perish. Yet unrelieved the mortality 
is not less than 90 to 95 per cent. 

In the treatment of incomplete rupture child and placenta should 
immediately be delivered. Forceps or podalic version may be chosen, 
but the latter is seldom permissible. When extraction by other means 
is likely to be difficult, delivery by perforation in the grasp of the 
cephalotribe is generally advisable. When the child is dead the latter 
procedure is clearly indicated. If the placenta has escaped into the 
peritoneum, it may rarely be extracted through the rent by the hand in 
the uterus with the aid of gentle traction upon the cord. 

After extraction of child, placenta, and blood-clots the location and 
extent of the rent should be determined with the hand in the uterus. 
Li incomplete rupture of moderate extent and limited to the upper 
uterine segment, no other treatment usually is required than to promote 
firm uterine contractions. 

In subperitoneal lacerations involving the lower segment of the uterus 
aii extraperitoneal hematoma is generally developed. Such cases may be 
trusted to thorough evacuation of blood-clots, the control of arterial hem- 
orrhage from the cervix by haemostatic suture, and a gauze drain loosely 
placed in the rent. The gauze may be removed in twenty-four hours. 



ANOMALIES ARISING FROM ACCIDENTS OR DISEASE. 511 

The death of the mother may result from shock, from primary or 
secondary hemorrhage, or from sepsis. More than one-half of the deaths 
occur within the first forty-eight hours after the injury. In pre-anti- 
septic days the outlook was still more gloomy, but with the increasing 
knowledge of abdominal surgery, and the better operative technique of 
the present day, the results have much improved. The following statis- 
tics from Schultze show the percentage of recoveries under different 
methods of treatment : 

Complete rupture without treatment, 20.2 per cent. 

Complete rupture treated with drainage, 36 per cent. 

Complete rupture treated by laparotomy, 44.7 per cent. 

As will be seen, the best results are obtained by the employment of 
surgical measures, and the prognosis is in some measure dependent on 
the promptness with which resort is had to operative interference. 

In incomplete rupture the consequences are less serious. As a rule, 
good results may be expected with the arrest of hemorrhage, complete 
evacuation of blood-clots, and proper drainage. 

Treatment. Prophylaxis. Essential to the prophylaxis of uterine 
rupture is prompt recognition of conditions which may act as predisposing 
causes. In the presence of vigorous uterine contractions with no 
progress, excessive thinness of the lower uterine segment is to be sus- 
pected and examined for. When BandPs ring is felt more than half- 
way from the pubes to the umbilicus labor should be ended as speedily 
as possible. The procedure to be adopted will depend upon the condi- 
tions present. In all cases an anaesthetic, and preferably chloroform, 
should be administered to the full surgical degree, to secure complete 
relaxation of the uterus. The uterus must be emptied promptly and 
with the least possible violence. In transverse presentation version 
is scarcely permissible, and decapitation will generally be required. In 
head presentation, if the child is living and the head has already en- 
gaged, the cautious use of forceps should be tried ; but if difficulty is 
experienced in applying the blades the attempt should be abandoned. 
Two methods of procedure are then left to the obstetrician — Caesarean 
section or craniotomy on the living child. It is needless to say that the 
latter alternative should be adopted only as a last resort, if the child is 
viable. 

When the proof of the child's death is conclusive embryotomy is 
clearly indicated. Podalic version should never be attempted, owing to 
the great danger of precipitating rupture of the overstretched uterine 
walls. 

Treatment of Complete Rupture, (a) Drainage. In complete rupture 
drainage may suffice when the rent is situated posteriorly if the injury is 
not extensive, if child and placenta have been extracted through the 
natural passages, and there is reason to believe that there is little or no 
blood in the peritoneum and that the uterus is not infected. Prolapsed 
loops of intestine are reposited, and a drain of wicking or of loose gauze 
rope is pushed through the rent, barely entering the peritoneum. The 
drain is removed in one or tw T o days. Ruptures of the anterior wall are 
obviously not amenable to drainage. 

(b) Cosliotomy. The abdomen should be opened, if the condition of 
the patient permits, in complete ruptures situated anteriorly, in extensive 



512 PATHOLOGY OF LABOR. 

laceration of the posterior wall involving the peritoneum, in all cases in 
which the child has wholly escaped into the peritoneum or in which the 
child has been dead for several hours. Abdominal section is indicated, 
too, when there is much blood in the peritoneum or the uterus is pre- 
sumably infected. In the presence of extensive or complicated injuries 
or of probable infection partial or complete hysterectomy offers the best 
chance of recovery. When there is reason to believe that the uterus is 
aseptic, clean-cut lacerations of moderate extent may be closed by two 
or three layers of suture, as the wound is closed in Cesarean section. 
The usual toilet of the peritoneum must be carried out, and if thought 
best a gauze drain through the posterior vaginal wall may be left for 
one or two davs. 



Rupture of the Symphysis Pubis. 

Swelling and softening of the ligaments and cartilages of the pelvic 
joints occur in slight degree during pregnancy, especially at the sym- 
physis pubis. The softening is usually so slight as to give rise to little 
or no appreciable separation ; exceptionally it is sufficient to result in 
perceptible mobility of the pubic bones upon each other. According to 
Stoltz, the separation may result from excessive softening of the joint- 
structures or from direct violence during operative efforts at delivery, 
whether complicated or not with excessive relaxation of the joint-struct- 
ures : the former accident is known as relaxation of the joint ; the 
latter, occurring during labor, as rupture of the symphysis. 

Causes. The predisposing causes of this accident are osteomalacia, 
rachitis, syphilis, and tuberculosis. Any profound cachexia may favor 
pelvic contraction. Unusually large feetal head or faulty presentation 
predisposes to rupture of pelvic articulations. Spontaneous rupture of 
the symphysis is rarely possible. In the great majority of instances the 
rupture is due to forceps. Excessive or misdirected traction is most 
frequently responsible for the injury. Of twenty- three cases of rupture 
of the symphysis collected by Havajewicz forceps had been used in 
eighteen. 

Diagnosis. When rupture of the symphysis occurs during labor the 
patient usually experiences a sharp pain in the joint. There may be a 
sensation of tearing. A sudden advance of the presenting part usually 
attends the rupture. Sometimes the separation is accompanied by a 
crackling sound perceptible to the attendants, but it is not always present, 
nor is it pathognomonic, as the same sound may be produced by the 
cranial bones gliding over one another or over a prominence of the 
pelvis. Usually the mobility of the bones is perceptible to the patient 
on turning in bed during convalescence. In rare instances the patient 
may be unaware of the injury of the symphysis until she attempts to 
walk. In extreme separation of the pubic bones there occurs some degree 
of injury to one or both of the sacro-iliac articulations. 

The diagnosis is made by direct examination. With the index-finger 
introduced within the vagina behind the symphysis, and the thumb in 
front, the separation and mobility of the bones may readily be made out. 
The looseness of the joints is detected by alternately flexing and extend- 



ing one thigh, and by rotating it outward, while the other is firmly held 
by an assistant. After the patient is able to leave the bed the slightest 
mobility is appreciable by examination in the standing posture, the 
patient being required to rest her weight on one and the other foot 
alternately. 

The Prognosis may be grave if the vagina or bladder is torn. It is 
extremely so if the peritoneum is invaded by the laceration. In neglected 
cases permanent mobility of the joint may remain, with partial or com- 
plete inability to walk. 

Treatment. The treatment of rupture or relaxation of the symphysis 
when discovered at the time of the injury consists in immobilizing the 
joint for from four to six weeks by means of a firm pelvic bandage. The 
patient in the mean time mnst be kept in bed. The hammock bed of 
Quierel or of Ayres, as employed in the after-treatment of symphyse- 
otomy, may be utilized. Laceration of the soft parts should be repaired 
by immediate suture. Neglected cases may be successfully treated by 
vivifying the articular surfaces with a suitable instrument passed sub- 
cntaneously, and immobilizing the joint with a firm spica bandage, with 
rest in bed for a month or more. If pus forms, the abscess should be 
evacuated promptly. Wiring the bones together is not necessary, and 
yields no better result. 



Haematoma of the Vulva and Vagina. 

Extravasation of blood into the cellular tissue of the vagina and vulva 
occurs most frequently in the labia majora. Sometimes the primary 
seat of the effusion is in the labia minora, Rarely the hemorrhage 
takes place into the paravaginal tissues or the perineum. The hemor- 
rhage may be venous or arterial, usually the former. The extravasation 
begins generally during the second stage of labor, rarely after delivery. 
The tumor may become large enough to obstruct the birth, yet it seldom 
attains any considerable size before the expulsion of the foetus. The 
swelling is most commonly observed at one side of the vulva ; when 
within the vagina it is located either upon the posterior or the lateral 
aspect. Labarie has shown that the site of tumor is dependent upon 
the anatomical structure of the part affected. When the hemorrhage 
occurs beneath the skin of the perineal region the extravasation may 
extend down the thighs or upward on the abdomen ; when below the 
superficial fascia it remains localized. Extravasations which occur be- 
neath the deep fascia of the perineum may extend into either iliac fossa. 
When the blood is effused between the deep fascia and the peritoneum 
a hsematoma may form in the abdomen, extending as high as the umbili- 
cus. When either lateral or posterior wall of the vagina is the seat of 
the extravasation it is limited in extent by the dense fibrous layer 
surrounding the structure, and remains localized. 

Frequency. The accident is rare. Winckel estimates the frequency 
at 1 in 1600 labors, and Charpentier 1 in 2000. These estimates 
do not include cases of comparatively frequent occurrence in which there 
may be a slight capillary oozing, due to a varicose condition of the 
superficial veins of the vulva. 

33 



514 PATHOLOGY OF LABOR. 

Etiology. The principal predisposing cause of haematoma of the vulva 
or vagina is the obstruction to the local circulation occasioned by ad- 
vanced pregnancy. Other predisposing causes are deformity of the 
pelvis, disproportion between the foetus and the birth-canal, circulatory 
disease, or morbid changes in the blood. 

Anything which acts to increase the pressure in the already greatly 
distended veins may precipitate their rupture. Common exciting causes 
are blows, falls, or violent concussion, the unskilful use of the forceps, 
awkward attempts at version, and unusual size of the foetus. As a rule, 
the accident is spontaneous. 

Symptoms. The first to attract attention usually is a swelling either at 
one side of the vulva or within the vagina. The tumor appears most 
frequently during the severe pains of the second stage of labor, and 
usually develops rapidly. Upon examination there w T ill be found a 
tumor, smooth, circumscribed when small, but diffuse when very exten- 
sive, and imparting to the finger an elastic feel. Fluctuation may or 
may not be present. The tumor is generally of a dark, livid color, and 
the ecchymosis may involve ultimately a large area around it. If the 
formation of the thrombus occurs before the delivery of the child, it 
may obstruct the birth. When the tumor develops at the close of the 
second stage of labor its presence may interfere with the expulsion of 
the placenta, or, later, with the loehial discharge. With extensive 
extravasation the symptoms of internal hemorrhage are present, namely, 
feeble, rapid pulse, pallor, cold, clammy sweat, dimness of vision, shaWow 
respiration, etc. Finally, if the tumor ruptures, external hemorrhage 
of greater or less degree may be added to the foregoing symptoms. 

Prognosis. Hsematoma in this situation may terminate as do haeniato- 
mata in other localities : it may be absorbed ; it may become encysted 
and undergo fatty or calcareous degeneration ; it may rupture subse- 
quently, or become infected and suppurate. Suppuration is more likely 
to follow a spontaneous rupture than an open incision. The prognosis 
is generally good under proper treatment. The outlook is more favor- 
able when the tumor appears after delivery. The dangers to which the 
woman is exposed are hemorrhage, sepsis, and those of instrumental or 
manual delivery. 

Treatment. The prophylactic treatment in the presence of undue 
congestion of the venous circulation, or of small extravasations during 
the last weeks of pregnancy, consists in keeping the patient in the 
horizontal position for the most of the time. At labor measures to 
facilitate labor are indicated. Usually no premonitory symptoms are 
observed. 

The active treatment will vary according to the size of the tumor, the 
amount of pressure it exerts, and the time of its appearance. When 
the tumor appears before delivery, and by its size renders the passage of 
the child's head impossible without spontaneous rupture, an anaesthetic 
should be administered, the tumor should be freely incised, all clots 
turned out, the cavity irrigated with a weak antiseptic solution or with 
sterilized water, and the hemorrhage controlled by a firm gauze pack, 
and, if required, haemostatic sutures. The subsequent treatment will 
consist in daily irrigation and repacking the wound with gauze, allowing 
the cavitv to heal from the bottom by granulation. If the thrombus 



ANOMALIES AETSTXG FROM ACCIDENTS OR DISEASE. 515 

does not appear until after delivery, it is better treated by compression 
with a view to promoting absorption. The case should, however, be 
watched carefully, and, if spontaneous rupture threatens, the tumor 
should be opened and treated as detailed above. The cavity, as a rule, 
becomes septic. Extreme care is needed to prevent systemic infection. 
In case of excessive blood-loss the acute anaemia is to be treated as in 
other hemorrhages. 



CHAPTEE XXII. 

THE HEMORRHAGES. 

Hemorrhage from Partial Separation of an Abnormally Situated 
Placenta— Placenta Prsevia. 

Normally the implantation of the placenta is wholly within the 
upper uterine segment, and its attachment remains undisturbed till the 
foetus is expelled. When its site encroaches upon that portion of the. 
uterus which undergoes dilatation in the first stage of labor, the placenta 
is of necessity partially detached at the onset of labor or in course of the 
partial expansion of the lower uterine segment, which takes place during 
the later weeks of gestation, and hemorrhage follows from the torn blood- 
vessels. To this abnormal situation of the placenta is given the name 
Placenta Prcevia, since the placenta lies partly in advance of the 
foetus. To the form of hemorrhage occurring from prsevial placenta, 
Rigby applied the term unavoidable hemorrhage, in distinction from that 
proceeding from partial detachment of the normally situated placenta, and 
which he called accidental hemorrhage. 

Varieties. Four varieties are usually described : Lateral, in which 
the placenta extends into the lower uterine segment, but not to the 
internal os ; marginal, in which it barely reaches the internal os ; partial, 
in which the placenta is so placed that it partly overlaps the os after full 
dilatation ; and complete, in which it will wholly cover the fully dilated 
os. The term central placenta prsevia is sometimes employed to desig- 
nate a central implantation upon the lower uterine segment. But these 
terms are not all accurately descriptive, and the multiplication of varieties 
is needlessly confusing. It is sufficient to make two classes of cases : 
partial and complete placenta prsevia. 

The Source of the Hemorrhage is the uncovered portion of the placental 
site, sometimes the placenta as well. Hofmeier has shown that the lower 
uterine segment is supplied by a branch of the uterine artery which 
descends from the upper segment. The arrest of hemorrhage from the 
lower portion of the uterus after labor is largely due to the retraction of 
the contractile upper segment, diminishing the blood-supply to the lower. 

Before the expulsion of the foetus, retraction being incomplete or 
absent, there is a free exchange of blood between the active and the 
passive segments; hence the hemorrhage from the bared portion of the 
obstetric cervix in placenta previa. A placental cotyledon may bleed 
while partially detached, but after complete separation its vessels are 
obliterated by coagula. 

Frequency. The frequency of prsevia! insertion of the placenta is 
usually stated at about 1 in 1000 cases. This estimate corresponds very 
nearly with the results of Muller's investigation, who found 813 cases 
reported in 876,432 labors, and with the average statistics afforded by 
lying-in hospitals. The frequency is several times greater in multipara? 
than in women pregnant for the first time. 

( 516 ) 



THE HEMOBRHA GES. 51 7 

Structural Anomalies. Owing to the comparative thinness of the deciclua 
in the region of the os internum the praevial portion is less perfectly 
developed than other parts of the placenta. This gives rise to uneven- 
ness in thickness and to irregularity of form. Sometimes the placenta 
presents a horseshoe shape. There may be isolated cotyledons which are 
almost completely separate from the main structure. 

The thinned portion of the placenta has a comparatively insecure 
attachment, a fact which increases the tendency to hemorrhage. The 
rest of the organ is often abnormally adherent. Miiller found adhesion 
in 54 out of 142 cases of placenta praevia. The insertion of the cord is 
usually eccentric. 

Etiology. The causes of placenta praevia are not definitely known. 
Probable causes are conditions leading to tardy fixation of the ovum, 
permitting it to fall to the lower uterine segment. Atrophy of the 
decidua, relaxation and subinvolution of the uterus, chronic endome- 
tritis, new growths and malformations of the uterus are, accordingly, 
believed to be factors in the etiology. Consistently with this hypothesis 
low implantation of the placenta is most frequently met in women Avho 
have borne several children. It is said to occur oftener in multiple 
than in single foetation. 

Miiller finds the cause in arrested abortion. The ovum, he thinks, 
may be partially separated and displaced by uterine contractions, and find 
secondary attachment lower down. 

Osiander suggests that the influence of gravity should be taken into 
account in explaining low fixation. 

Recently Hofmeier aud Kaltenbach have proposed the theory that the 
anomaly may originate from the development of the placenta over the 
decidua reflexa of the lower pole of the ovum. Their views have not, 
however, met with universal acceptance. 

Hart maintains that the vicious insertion is primary. He believes 
that the human ovum can become engrafted only on a surface denuded 
of epithelium, and that the ovum may exceptionally meet with such a 
surface only in the lower uterine segment. Kaltenbach' s objection that 
the ovum could not find lodgement near the cervix, but would rather 
escape through it and be lost, he thinks, does not hold, since the os inter- 
num is practically obliterated by folds of the hypertrophied decidua. 
Ingleby found a low insertion of the Fallopian tubes in two remarkable 
cases, in each of which placenta prsevia had occurred in several successive 
pregnancies. 

Symptoms. Usually there are no symptoms in the earlier months of 
pregnancy ; yet placenta praevia is frequently an unrecognized cause of 
abortion. Generally the first indication is a sudden hemorrhage of 
greater or less severity. This may occur at any period of gestation, but 
is seldom noted except in the later months. The liability to hemorrhage 
increases with each succeeding month of pregnancy. Much bleeding 
from this cause is rare before the seventh month ; in the vast majority 
of instances the first attack is observed in the eighth or ninth. It comes 
on with no premonition, and generally without obvious exciting cause. 
Exceptionally the first hemorrhage follows some unusual muscular exer- 
tion. The amount of blood-loss varies with the conditions of the indi- 
vidual case. It is proportionate to the extent of placental separation. 



518 PATHOLOGY OF LABOR. 

It is greater usually the more nearly the praevial attachment is com- 
plete and the nearer to term the hemorrhage ; yet a marginal placenta 
prsevia may exceptionally give rise to copious flooding. From one to 
three pints of blood may be lost in the first attack in pregnancy, and 
this quantity may be greatly exceeded during labor. Characteristic of 
this form of hemorrhage is the fact that the flooding is most profuse in 
the intervals between the pains. During the height of the pain the blood- 
supply to the torn vessels is almost wholly interrupted by the contraction 
of the upper uterine segment. The first hemorrhage, especially if it occurs 
during labor, may go on to a fatal termination, or it may cease to be 
renewed at any day or hour on further separation of the placenta. But 
it is not alone the copious outpour of blood that is dangerous. In a 
certain proportion of cases the bleeding is slight but persistent, and if 
neglected, though at no time large in amount, it may ultimately place 
the patient's life in grave peril. To the clinical picture are frequently 
added the signs of acute anaemia; these are : pallor, perspiration, skin 
cold and clammy, respiration irregular, sighing, sobbing, yawning, pulse 
rapid, thready, compressible; thirst, jactitation, tinnitus aurium, air- 
hunger, nausea, dimness of vision, and syncope. 

Diagnosis. Hemorrhage during pregnancy, and especially in the later 
months, demands immediate investigation to ascertain its cause. Recur- 
ring hemorrhages near term are generally due to villous insertion of the 
placenta. This form of hemorrhage must be distinguished from so- 
called " accidental hemorrhage." The diagnosis must rest on the physical 
signs. 

Abdominal Signs. Frequently the location of the placenta, when the 
implantation is partly on the anterior wall of the uterus, may be made out 
by palpation over the abdomen. Sometimes the edge of the placenta 
presents a resisting ring perceptible by the abdominal touch. Within 
the placental area the foetal parts are felt indistinctly, owing to the inter- 
position of the placenta between the fcetus and the examining fingers, 
while elsewhere they are more readily made out. 

Vaginal Signs. In placenta prsevia ballottement is wanting or diffi- 
cult, as is also the recognition of the foetal parts by the vaginal touch. 
Owing to the interposition of the spongy placental tissue between the 
child's head and the fingers of the examiner, bogginess of the cervix, 
usually referred to as evidence of praevial insertion of the placenta, is 
not always sufficiently characteristic to be of diagnostic value. The 
only pathognomonic sign of placenta prsevia is the recognition of the 
abnormal situation of the placenta by the examining finger passed within 
the os. If labor has begun, the os will be found soft and patulous, 
and upon introducing the finger through the cervix the placenta may 
be identified by its characteristic stringy feel. To distinguish a com- 
plete from an incomplete placenta prsevia, the finger is passed well up 
on each side of the cervix, feeling for the margin of the placenta : if 
the fully dilated os is entirely surrounded by placental tissue, the 
placenta prsevia is complete ; if the finger can be introduced between 
the margin of the placenta and the wall of the cervix, the condition is 
one of incomplete placenta prsevia. 

Prognosis. Placenta prsevia is a dangerous complication of pregnancy 
and labor for both mother and child. Much depends, however, on the 



THE HEMORRHAGES. 519 

degree to which the placenta is previa, and in general the mortality is 
capable of great reduction under proper treatment. Churchill and Read 
place the maternal death-rate at from 25 to 33 per cent. In 67 cases 
recorded bv Barnes, 8.8 per cent, of the mothers were lost. Muller's esti- 
mate of the mortality is 23 per cent, for the mothers and 64 per cent, for 
the children. In 61 cases Murphy had but 2 maternal deaths. Winckel 
thinks that not more than 5 or 10 per cent, of the mothers should be 
lost. In 739 collected cases there were 57 maternal deaths in incomplete, 
and 109 in complete placenta praevia. It is the writer's conviction that 
under modern methods of treatment the maternal mortality should not 
exceed the limit stated by Winckel, and the foetal should not be more 
than 50 per cent. The risks to which the mother is exposed are not only 
those of the primary hemorrhage, but also those of operative interfer- 
ence and of the sequela?. Malpresentations and malpositions of the 
foetus and prolapsus funis are more frequent in placenta praevia than in 
normal placental implantation, and there is greater risk of infection 
during labor, of post-partum hemorrhage, and of thrombotic affections. 
Treatment. The chief element of danger in placenta praevia is hemor- 
rhage, and the control of hemorrhage is, therefore, the principal indica- 
tion in the treatment. Here, as in general, while the child's life must 
not be undervalued, the interests of the mother are paramount. It will 
be convenient to consider the management of placenta praevia under the 
following heads : 

(1) Before the Fcetus is Viable. The death of the mother, by 
reason of vicious insertion of the placenta, is extremely rare before the 
end of the seventh month of gestation. A partially expectant plan of 
treatment is usually permissible till the viable period is reached, in the 
hope of saving the child. This course is the more justifiable in hospital 
practice, where the woman can be kept under close observation, and 
measures for the control of hemorrhage can be promptly enforced should 
the occasion arise. Quiet, and if need be, rest in bed must be enjoined. 
The avoidance of much muscular exertion and of the causes of pelvic 
congestion, including coitus, is imperative. Vaginal douches of hot 
water and vinegar, as advised by Winckel, are of doubtful utility. 
They are liable to defeat their own object by provoking uterine contrac- 
tions. 

If the foetus is dead the uterus should immediately be emptied. The 
latter treatment is usually indicated, too, if the hemorrhage is profuse or 
persistent. 

(2) After the Fgetus is Viable. Nearly all the fatal termina- 
tions in placenta praevia occur after the seventh month of pregnancy. 
The development of the utero-placental circulation increases with each 
succeeding month, and the danger is greater the nearer the case is to 
term, In the later weeks of gestation the woman is constantly exposed 
to the risk of hemorrhage, which may go to a fatal extent before medical 
aid can reach her. In all except simple marginal placenta praevia, with 
little or no hemorrhage, the pregnancy should be terminated immediatelv 
the period of full foetal viability is reached, if the condition has been 
discovered. Moreover, it is imperative that the physician remain with 
the patient till labor is complete. 

If the development of the foetus has passed the seventh month, its 



520 PATHOLOGY OF LABOR. 

chances for survival are fully as good by premature evacuation of the 
uterus as by waiting till repeated hemorrhages have occurred, since, after 
much bleeding, the danger from asphyxia is exceedingly great. 

Management of Labor. The induction of labor is conducted in accord- 
ance with the usual rules. Krause's method — passing one or two bougies 
between the membranes and the uterine wall — may be elected when time 
permits. A water-bag may also be placed in the cervix for the double 
purpose of preventing hemorrhage and of provoking uterine contrac- 
tions. When more rapid delivery is indicated, the cervix should be 
dilated by the use of the water-bag till the os internum is effaced. The 
dilatation may then be completed by the manual method. A firm abdom- 
inal binder is applied as a safeguard against the accumulation of blood 
in the uterus. Measures for controlling hemorrhage during labor are 
the following: 

Rupture of the Membranes in Partial Detachment of the 
Placenta. In mere marginal placenta prsevia the hemorrhage may 
frequently be controlled by rupturing the membranes, and, if necessary, 
stimulating the uterus to contract. On escape of the waters the foetus 
is driven down by the uterine contractions and the bleeding is partially 
or wholly arrested by the pressure of the presenting part. An abdom- 
inal bandage is a valuable aid for maintaining this pressure. This pro- 
cedure usually suffices in the class of cases referred to, and it has the 
advantage of simplicity. The progress of dilatation is somewhat retarded, 
but that is a matter of minor importance in comparison with the effects 
of much blood loss. The method is suited, however, only to cases in 
which the placental insertion encroaches but little upon the dilating zone 
of the uterus. It is positively contraindicated in conditions which may 
necessitate version. 

In addition to the perforation of the bag of waters, the presenting edge 
of the placenta should be separated from the lower uterine segment. 
The finger is passed through the cervix and the placental margin peeled 
up as far as the finger can reach easily. This favors retraction of the 
lower uterine segment and ligation of the torn vessels. 

Should the bleeding still continue, a water-bag may be introduced, or 
when the dilatation is sufficient the forceps maybe applied, if the vertex 
presents, and gentle traction be made to hold the head in the lower 
uterine segment. If the breech presents, one or both feet should be 
brought down as soon as the dilatation permits. 

Vaginal Tamponade. The vaginal tamponade is a valuable measure 
in cases in which there is hemorrhage with little or no dilatation of the 
cervix. The vaginal tampon, if it is properly applied and the uterus 
is supported by an abdominal binder, effectually controls the bleeding. 
The method of procedure is as follows : The bladder and the rectum 
should be empty. The Sims position is best, since in this posture the 
uterus falls toward the diaphragm and the vagina becomes fully dis- 
tended with air when the pelvic floor is retracted with the speculum. 
The material for the tampon may be absorbent cotton or strip gauze, 
either plain or impregnated with iodoform or with oxide of zinc. The 
gauze has the advantage that it may easily be removed. The strip 
may be three or four inches in width. Whatever the material, it 
should be wet, in order to pack firmly. If the vagina is healthy and has 



THE HEMORRHAGES. 



521 



not been infected by previous manipulations, no preliminary internal 
cleansing is necessary. In all other respects the usual antiseptic pre- 
cautions must be observed. The material used for the vaginal tampon- 
ade must be aseptic ; it is not necessary that it be antiseptic. No 
harm will be done, however, by impregnating it with some feebly 
toxic antiseptic. Mercurials are especially unsuitable for the purpose, 
owing to the danger of intoxication. If absorbent cotton is to be used 
for the tampon, twenty or thirty pledgets of the size of an English 
walnut should be in readiness. The patient is placed in Sims's posi- 
tion ; a Sims speculum is introduced and held by an assistant. A con- 
venient forceps for carrying the cotton balls is a straight Keith. The 
first pledget is placed behind the cervix, the next in front of the 
cervix, then one at each side. The intervening spaces are filled, and a 
second layer packed on the first. This is continued until the vagina 
is filled and the packing protrudes at the vulva. A pad of absorbent 
cotton is placed over the external geuitals, and over this a firmly applied 
T bandage, which holds the tampons securely iu place. If gauze is used 
it is packed in similar manner. The vaginal tampon is removed in eight 
to twelve hours, by which time the labor will in most cases have pro- 
gressed sufficiently to be managed by other means. Should there still 
be bleeding, and the dilatation not have progressed far enough to efface 
the os internum, the packing may be renewed. 

Cervical Tamponade. Equally efficient for the control of bleeding 
in placenta previa during the begiuning dilatation of the cervix is the 



Fig. 33' 




Barnes's dilating water-bags. 



complete occlusion of the cervical canal. This is effected by means of 
an elastic bag, which is introduced within the cervix and distended till 
the canal is successfully plugged. Available for this purpose are the 
fiddle-shaped bags of Barnes and of McLean, that of Tarnier, and the 
Champetier de Ribes ballon. A tube is attached to the bag through which 
the latter may be filled. For introduction of the dilating bags the patient 
may lie in the lithotomy position, the cervix being held well forward 
toward the pubes by means of a volsella caught in the anterior lip. One 
or two fingers are introduced within the vagina and the instrument 



522 



PATHOLOGY OF LABOR. 



passed on these as a guide. The Sims position, however, is usually to be 
preferred. With the perineum retracted by means of a Sims speculum, 



Fig. 33 




McLean's bag. 



and the cervix drawn forward, the os externum is readily brought into 
view. The dilating bag is rolled snugly into a cylindrical shape, seized 
with a long forceps, and lodged in the cervix. The forceps is then with- 
drawn and the bag distended. As a precaution against infection, should 
the bag accidentally be ruptured, boiled water or a mild antiseptic solu- 
tion should be used for filling the bag. Air is unsuitable, owing to the 
risk of air embolism should the bag burst. The water is injected with a 
Davidson or similar bulb-syringe provided with a nozzle which fits the 
tube. As a precaution against overdistention the operator should know 
by previous trial how many bulbf uls are required to expand the bag to 
its limit. A rigid asepsis must, of course, be observed. 

The cervical tampon has the double effect of controlling hemorrhage 
and at the same time promoting the dilatation of the cervix more effect- 
ually than does the vaginal packing. It has the advantage over the 
latter of causing less discomfort to the patient. When thought necessary 
both these measures may be employed. As a rule, they are to be replaced 
by other measures after the os internum is effaced. This is usually accom- 
plished in at most eight or ten hours. Yet, when time permits, the labor 
may satisfactorily be completed with the aid of the dilating water-bag. 
The Champetier de Ribes bag is especially to be recommended after the 
dilatation of the cervix is well established. In the interest of asepsis it 
is best introduced within the amniotic sac, since direct contact of the bag 
with the bared surface of the uterus is thus avoided. 

Manual Dilatation. Manual dilatation, or the so-called accouche- 
ment force, which has recently been advocated by Fournier and other 
authorities for the treatment of placenta prsevia, is seldom permissible, 
except for completing the canalization of the utero-cervical zone after it 
is already well advanced. To a woman who has already sustained much 
blood-loss, forcible and rapid dilatation of the cervix a b initio is danger- 
ous, owing to the shock involved. A considerable hemorrhage must 
necessarily occur during the dilatation, and the fingers in the cervix 
afford a very imperfect means for controlling it. The danger, too, of 
uterine rupture and of infection is increased in low implantation of the 
placenta, and this is an objection to accouchement force. 

Podalic Version. One of the most effectual measures for the con- 
trol of hemorrhage in placenta prsevia is podalic version, and no method 



THE HEMORRHAGES. 523 

has yielded better results. With one or both feet brought down the 
foetus serves as a conical plug, which is forced down or can be drawn 
down as fast as the dilatation progresses. The cervix is thus securely 
tamponed during the entire course of the birth. Lomer, of Berlin, 
reports a maternal mortality of 4 J per cent, iu 101 cases treated by 
version. It must not be forgotten, however, that any kind of violent 
iuterference is unsafe when the woman has lost much blood. If, there- 
fore, much bleeding has occurred, version is to be undertaken only when 
little difficulty is likely to be encountered. 

In most cases it is a grave mistake to add the shock of immediate 
delivery to that of version. The excellent results of version in placenta 
praevia have been obtained only when the operation has not been fol- 
lowed by immediate extraction. Either the external, the bipolar, or the 
internal method may be chosen, according to the conditions present. 
External version before labor is exceptionally possible. The bipolar 
method of Braxton Hicks has the advantage over internal version that 
it can be performed early in the labor, as soon as one or two fingers can 
be passed through the os uteri, and there is less danger of infection than 
when the whole hand is introduced. The fingers passed through the 
membranes, one or both feet are seized with the hand and brought down. 
"When the placental margin cannot readily be reached, in emergency the 
placenta maybe perforated and the feet brought down. With the foetus 
inverted the hemorrhage is completely under control, and the delivery 
can usually safely be left to nature. Barely it may be necessary to assist 
the birth, taking plenty of time, delivering very slowly. 

For the full technique of the different methods of version the reader 
is referred to the chapter on Obstetric Surgery. 

Other Methods. Partial Separation of the Placenta. Separation of 
the presenting portion of the placenta, as proposed by Barnes, often 
suffices in marginal implantation. It permits retraction of the zone 
uncovered. In most instances of this form of placenta praevia no other 
treatment will be required. One or two fingers are passed between the 
placental edge and the uterine wall, and the margin of the placenta is 
peeled up by sweeping the fingers laterally. The detachment should be 
carried far enough to uncover completely the dilating zone of the uterus. 
An abdominal binder should be applied. 

Complete Separation of the Placenta, as advised by Simpson, is appli- 
cable in case the child is dead or not yet viable. 

Precautions. It must not be forgotten that the essential object of 
treatment in placenta praevia is the control of hemorrhage. Hemorrhage 
under control, there is no occasion, as a rule, for active interference. Vio- 
lent measures are especially contraindicated in the acute anaemia which 
often obtains in this class of cases at labor. Very little shock in such con- 
ditions will frequently precipitate a fatal issue. A large proportion of 
deaths in placenta praevia is distinctly chargeable to over-zealous inter- 
ference. 

Owing to the low placental site and the intra-uterine manipulations 
usually required, the risk of sepsis, too, is much greater than inordinary 
labors. Precautions against sepsis must rigidly be observed. 

Post-partal hemorrhage is of frequent occurrence. The vessels of 
the placental site are not so securely ligated after labor, when the 



524 PATHOLOGY OF LABOR. 

implantation is on the lower and less contractile portion of the uterus, as 
in normal conditions. The amount of post-partum flow must always be 
watched. Retraction of the uterus should promptly be secured and rigidly 
maintained. Ergot should be given for two or three days after labor. 

Hemorrhage from Premature Separation of a Normally Situated 
Placenta; Accidental Hemorrhage. 

Hemorrhage may occur during labor or the later weeks of pregnancy, 
as the result of a premature, partial, or complete detachment of a nor- 
mally inserted placenta. To this form of bleeding Rigby, as already 
explained, applied the term accidental hemorrhage. 

Hemorrhage of this character is exceedingly rare, occurring once in 
8000 or 10,000 cases. Goodell, in 1870, had collected but 106 cases. 

Varieties. Two varieties of accidental hemorrhage are usually de- 
scribed : apparent, and concealed or internal hemorrhage. In the first 
variety the blood finds its way between the membranes and the decidua, 
and escapes through the cervix. In the second variety, the blood fails 
to find an outlet, and may collect in sufficient quantity within the uterus 
to occasion alarming symptoms or even death, with no visible bleeding. 
The former variety is the most frequently met. 

In the concealed form, according to Goodell, either of the following 
conditions may obtain : 1. The placenta may be detached at the centre, 
the margin being still adherent. 2. The placenta may be detached at 
one edge, the membranes being separated for a short distance beyond the 
placental margin. 3. The edge of the placenta and the adjacent portion 
of the membranes being detached, the latter may rupture, permitting 
escape of blood into the amniotic sac. 4. Detachment of the placenta 
may take place, accompanied with separation of the adjacent membranes, 
but the foetal head, acting as a ball valve, or a blood-clot in the cervix, 
may prevent external escape of the blood. 

While the first attack of hemorrhage may occur after labor has com- 
menced, almost invariably it takes place during the last three months of 
pregnancy. 

Etiology. Probably the most common predisposing cause is to be 
found in a diseased condition of the decidua or in certain morbid states 
of the placenta itself. Tubercular and syphilitic degenerations of the 
lining of the uterus are recognized causes. Cases have been reported 
in which the placenta was found to be the seat of a beginning fatty 
and calcareous degeneration. Nephritis, extreme anemia, diabetes, and 
some of the acute infectious diseases, as scarlatina, diphtheria, and variola, 
have been assigned as etiological factors. Certain anomalies of the foetal 
appendages, great distention of the uterus, and short cord may favor 
premature separation of the placenta; most cases occur in multipara? who 
have borne many children or whose general health is impaired. In the 
presence of any of the foregoing predisposing causes, it is easy to under- 
stand how an apparently trivial exciting cause may give rise to slight 
separation of the placenta from its attachment to the uterine wall. 
Thus, trauma, as by a blow on the abdomen, a fall, violent muscular 
exertion, and emotional disturbances, etc., must be counted among the 
exciting causes of accidental hemorrhage. 



THE HEMORRHAGES. 



525 



Fig. 



Diagnosis. Apparent Variety. The existence of hemorrhage is 
obvious. Rupture of the uterus and placenta prsevia roust be excluded. 
The former occurs later in the labor than does accidental hemorrhage, 
and is characterized by recession of the presenting part, diminution of 
the uterine tumor and the development of a new abdominal tumor; 
placenta pravia is readily differentiated by a physical examination. In 
accidental hemorrhage the uterine tumor is increased in size, and the 
flooding usually takes place before the rupture of the membranes. 

Concealed Variety. First to attract attention usually are the 
systemic effects of hemorrhage. If the blood effusion is extensive, the 
fact is betrayed by pallor, anxious expression of countenance, cold 
extremities, feeble and rapid pulse, sighing respiration, collapse. The 
uterine contractions are weak, yet continuous uterine pain is sometimes 
present, owing to distention of the perimetrium. 

On abdomiual examination, bulging of the uterine wall may be noted 
at the seat of the blood collection ; the uterine tumor presents a boggy 
feel, the foetal parts are indistinctly felt, and the foetal heart-sounds are 
feeble and irregular. The condition may sometimes be detected by 
pushing up the presenting part and allowing a portion of the blood and 
liquor amnii to escape. It should not be 
forgotten that concealed may coexist with 
an insignificant external hemorrhage. 

Concealed accidental hemorrhage might 
be confounded with ruptured tubal preg- 
nancy, but the latter is readily distin- 
guished by physical exploration and by its 
history. 

Prognosis. In apparent hemorrhage the 
prognosis is good for the mother, but is 
frequently fatal for the child. In the 
concealed variety the prognosis is grave. 
The maternal mortality is more than 50 
per cent., while about 90 per cent, of 
the infants are lost. The high death-rate 
in case of the mother is due to extreme 
anaemia, sepsis, post-partum hemorrhage, 
and to shock and exhaustion from over- 
distention of the uterus. The foetal mor- 
tality arises chiefly from asphyxia, the 
result of interruption of the utero-placental 
circulation. Prematurity is sometimes a 
factor. 

Treatment. In the external variety of 
hemorrhage, if the bleeding is moderate 
in amount, the mother's condition being 
fairly good, and the foetus Still viable, Frozen section ofthe uterus of a woman 
the only treatment demanded is rest in wno di ed of accidental hemorrhage at 
bed, a full dose of opium, and absolute 
quiet for a week or ten days. Even a 
moderately free hemorrhage may sometimes be arrested by these means. 

In either variety, when the blood-loss is alarming, the uterus must be 




the Maternite de Beaujon. (Pinard and 
Varnier.) 



526 PATHOLOGY OF LABOR. 

emptied. If the os is partially dilated, the membranes should at once be 
raptured. If the os is small and rigid, the vaginal tampon, or, better, 
a Barnes cervical dilator may be employed. This temporarily arrests 
the bleeding and at the same time dilates the cervix. While the use of 
the vagiDal or the cervical tampon is open to the objection that it may 
convert an external into a concealed hemorrhage, this is scarcely possible 
if the uterus is firmly supported with a tight abdominal bandage. After 
the membranes have ruptured the tampon is contraindicated. When 
immediate delivery is demanded the cervix may be incised. 

If the condition of the mother permits, it is usually advisable to wait 
till the os is partially dilated before rupturing the membranes, as then ver- 
sion by Hicks' s bipolar method may more easily be performed. Goodell, 
however, advises early rupture of the membranes, immediately followed 
by the application of a very tight abdominal binder over a pad placed 
above the fundus of the uterus, together with the free administration of 
ergot. Labor should be terminated as speedily as possible by manual 
dilatation and version, or forceps. 

If the patient's condition is such as to forbid active obstetric inter- 
ference, she should be stimulated freely, the foot of the bed should be 
elevated, and means taken to replace the blood lost by hemorrhage before 
subjecting her to the additional shock of version. The relaxed uterus 
should be made to contract by means of friction or compression of the 
fundus, a firm abdominal compress, and the administration of small 
doses of ergot. 

If the child has perished, craniotomy is advisable if the os is not 
fully dilated. Csesarean section, which has been advocated by certain 
authorities, can seldom be justified. 

The after-treatment consists in measures intended to promote uterine 
contraction and in the treatment of acute anaemia. The woman is espe- 
cially liable to post-partum hemorrhage. The treatment, both prophy- 
lactic and remedial, is the same as for post-partal hemorrhage under other 
conditions. 

The shock and collapse of anaemia are to be combated with strych- 
nine, alcoholic stimulants, and by submammary or intravenous injections 
of normal salt solution. Elevating the foot of the bed and auto- 
transfusion, by bandaging the extremities, are useful expedients. 



Post-partal Hemorrhage. 

There is no emergency in obstetric practice that more seriously jeop- 
ardizes the patient's life, that calls for more prompt and energetic treat- 
ment, none in which the courage and skill of the obstetrician are more 
abruptly put to the test, than in severe post-partal hemorrhage. The 
obstetrician is usually dependent solely upon his own resources. There 
is no time for consultation ; a few moments may turn the scale either for 
or against the patient's recovery. Fortunately for both patient and 
physician, this, as a rule, is a preventable accident. 

Spiegelberg declares that grave post-partal hemorrhage is almost 
without exception the fault of the medical attendant. The fact cannot 
be too strongly impressed upon the student's mind, that with proper 



THE HEMORRHAGES. 527 

management of the third stage of labor post-partal hemorrhage is one 
of the rarest of accidents. 

Etymologically, the term post-partal hemorrhage applies to a hemor- 
rhage arising at any time after the birth of the child and from whatever 
cause. The term, however, in its technical sense, is restricted to hemor- 
rhage from the uterine cavity occurring during the first few hours after 
the child is delivered ; in the great majority of instances it takes place 
before or immediately after the placenta is expelled. 

The term " secondary post-partal hemorrhage," or puerperal hemor- 
rhage, is applied to flooding coming on after the first six hours of the 
puerperium. 

Hemorrhage from rupture or inversion of the uterus, malignant or 
benign growths of that organ, or from lacerations of the cervix or 
vagina, are not included under post-partal hemorrhage in the technical 
sense of the term. 

Frequency. The records of hospitals and large lying-in institutions, 
from which statistics are mainly gathered, and in which the labors are 
conducted presumably by men of special skill, naturally show a smaller 
frequency of cases of post-partal hemorrhage than is observed in pri- 
vate practice. Playfair considers post-partal hemorrhage of some degree 
one of the commonest complications with which the obstetrician has to 
deal. On the other hand, the records of Guy's Hospital furnish but 1 
case of dangerous post-partal hemorrhage in 2040 labors ; St. Thomas's 
Hospital reports give 1 in 2172 labors; Veit, from the statistics of a 
number of Continental authorities, was able to collect only 5 fatal 
cases in 47,765 deliveries. This latter statement certainly underesti- 
mates the death-rate from this cause. In general, it may be stated that 
mild post-partal hemorrhage occurs once in 100 labors ; severe, once 
in from 1000 to 1200 ; and fatal hemorrhage once in from 4000 to 6000 
labors. 

Etiology. First The principal cause of post-partal hemorrhage is 
uterine inertia or atony of the uterine muscle. Normally, with the sepa- 
ration of the placenta there is a certain amount of blood-loss, which, 
however, is quickly controlled by the firm contraction of the uterus ; the 
uterine sinuses are closed by the contraction of the network of muscular 
fibres w r ith which the bloodvessels of the uterus interlace. Hemorrhage 
of any considerable amount cannot take place from the cavity of a thor- 
oughly and permanently contracted uterus. 

There are numerous remote causes which contribute directly or indi- 
rectly to the occurrence of post-partal hemorrhage. Prominent among 
them is exhaustion following a prolonged and difficult labor. 

After precipitate labor and sudden expulsion of the child, flooding may 
occur before time enough has elapsed for uterine retraction to take place. 
Overdistention of the uterus, as in hydramnios, multiple pregnancy, etc., 
frequently results in uterine inertia ; a distended bladder or rectum tends 
to inhibit normal uterine contractions. The retention of secundines or 
of blood-clots may prevent full uterine retraction and the secure ligation 
of its vessels. New growths in the uterus may have a like effect. Pro- 
found anaesthesia continued for a long time tends to more or less com- 
plete atony of the uterus. Certain constitutional diseases predispose to 
this accident, as nephritis, extreme anaemia, and haemophilia. Hemor- 



528 PATHOLOGY OF LABOR. 

rhage after labor may be precipitated by sudden emotional disturbance. 
Inertia uteri, in the final as in the earlier stages of labor, is more com- 
mon among the wealthy than among the poorer classes, owing to lux- 
urious habits, lack of exercise, and general laxity of the muscular system, 
which is the rule among the former. Uterine inertia is more commonly 
observed in women who have borne many children and in whom the 
abdominal walls are lax, or in old primiparae who are much debilitated. 
Veit refers to a localized paralysis of that portion of the uterine walls 
to which the placenta was attached as an occasional cause of post-partal 
hemorrhage. 

Second. Placenta prsevia exposes to post-partal hemorrhage. The 
lower segment of the uterus has but little contractile power at the close 
of labor. Hence, after complete separation of a placenta from the lower 
uterine zone bleeding may follow from the relaxed lower uterine segment. 

Third. Earely the hemorrhagic diathesis is encountered in obstetrics 
as in other fields of practice. Here the gravity of the complication is 
due more to the persistence of a moderate hemorrhage than to profuse 
flooding. 

Symptoms. The bleeding may occur before or after the expulsion of 
the placenta. Most frequently it takes place within a few moments after 
the birth of the child. It may be gradual or abrupt. The bleeding may 
be external, internal, or both. Commonly, when hemorrhage results from 
uterine inertia, considerable accumulation of blood takes place within 
the uterus. One of the most notable effects of hemorrhage is lessened 
force and increased frequency of the pulse. A high and rising pulse- 
rate following delivery is always significant of possible hemorrhage. A 
patient with a pulse remaining at 100 or more after labor should con- 
stantly be watched till all danger of flooding has passed. 

The patient may herself give the first warning that she is flooding; 
after much bleeding she presents the usual symptoms of acute anaemia. 
The pulse becomes rapid, thready, and, in extreme cases, almost impercep- 
tible. The respirations are shallow and rapid, or gasping ; the patient 
tosses about the bed, and she complains of air-hunger and thirst. The 
skin is cold and covered with a clammy sweat. Syncope is generally 
conservative, since it favors thrombosis in the uterine sinuses and arrest 
of the bleeding. If the hemorrhage continues, loss of consciousness, 
convulsions, and death quickly close the scene. 

The existence of external hemorrhage is obvious. In concealed bleed- 
ing the condition is recognized by the presence of some of the above- 
mentioned symptoms. With the hand placed on the abdomen above the 
symphysis, instead of feeling the uterus as a hard globular tumor 
between the umbilicus and the symphysis, it will be found soft, boggy, 
and extending perhaps above the umbilicus ; not infrequently no uterine 
globe can be made out. 

Prognosis. The prognosis must clearly depend upon the amount of 
blood-loss and the nature of the causes which have led to it. The most 
unfavorable cases are those in which, though the hemorrhage is not severe, 
the blood is light-colored, contains no clots, and is indicative of a blood 
dyscrasia. Playfair says : " Recovery is often possible after the vital 
forces have seemingly reached their lowest ebb. If the hemorrhage can 
be arrested while there is still some power of* reaction, life may yet be 



THE HEMORRHAGES. 529 

saved. Recovery after severe post-partal hemorrhage is exceedingly 
slow, and it may be weeks or months before the patient regains her 
usual vigor. 

Treatment. Prophylaxis. Post-partal hemorrhage is a prevent- 
able accident. The preventive treatment must be directed to the uterine 
retraction. In all cases the hand of the obstetrician or an assistant 
should be held on the abdomen over the uterus from the moment the 
child is born till the placenta is expelled ; and after the expulsion of the 
placenta the uterus should be watched, for at least an hour, in the same 
manner, by the physician. Any tendency to abnormal relaxation should 
immediately be combated by friction or, if need be, by more active 
manipulation. "When the uterine contractions are feeble, ergot should 
be given by the mouth or hypodermically. A sufficient dose ordinarily 
is a half drachm repeated hourly till retraction is fully established. This 
precaution is especially advisable after chloroform anaesthesia. Finally, 
a firm abdominal binder may be used to maintain uterine retraction. 
When special precautions are needed, compresses consisting of folded 
towels may be placed under the bandage, one on either side of the uterus 
and one immediately above it. When the management of the post- 
partal period is properly carried out, the occurrence of grave hemor- 
rhage must be exceedingly rare. 

Active Treatment. The occurrence of post-partal hemorrhage 
demands prompt and vigorous measures. The obstetrician should be so 
familiar with the resources at his command for the arrest of uterine 
hemorrhage that no time may be lost in deciding upon the choice of 
procedure. All needed preparations should be ready for instant use 
should abnormal bleeding occur. 

On the occurrence of hemorrhage of the kind under discussion the 
paramount indication is to secure uterine contraction. The patient 
should be placed on her back, the pillow removed from beneath her 
head, and the foot of the bed elevated. All this may be done by an 
assistant. The hand placed flat upon the abdomen moves the abdominal 
wall in a circular direction over the uterus. The uterus is quicker to 
respond to vigorous friction than to direct pressure exerted at any one 
point. After the uterus becomes slightly contracted, so that its outline 
is defined, the fingers are pressed deeply into the abdominal wall behind 
the uterus, while the thumb remains resting over the anterior surface. 
Thus the fundus of the uterus rests in the palm of the hand, by which 
it is to be forcibly grasped. If necessary, both hands may be used. Such 
compression tends to expel clots and to control the hemorrhage. 

It may be necessary to introduce one hand into the uterus to remove 
placenta, membranes, or clots. Frequently this procedure will serve 
the double purpose of emptying the uterus and, by the stimulating 
effect of the hand in utero, of provoking strong contractions. If the 
hand is protected by a sterile rubber glove, the danger of infection is 
minimized. 

In profuse or persistent hemorrhage one hand should always be intro- 
duced into the uterus. With the internal hand closed, the other held 
over the abdomen, the uterus may be compressed between the two hands. 
Raking the uterine wall vigorously with the finger-tips is a most effectual 
method of exciting contraction. Hamilton suggests passing the fingers 

34 



530 



PATHOLOGY OF LABOR. 



of one hand well back into the posterior cul-de-sac of the vagina, while 
the external hand, grasping the fundus through the abdominal wall, 
makes counter-pressure. The uterus is thus strongly anteflexed. Some- 
times, instead of this, the uterus may be crowded down with one or both 
hands on the abdomen and compressed against one iliac fossa. 



Fig. 340. 




Bimanual compression producing anteflexion. (Schroeder.) 

Compression of the abdominal aorta as a temporary means of con- 
trolling this form of hemorrhage has long been practised. Its great 
virtue lies in the fact that it can easily and quickly be applied, and it 
often enables the physician to gain time for other procedures. 

While the physician is thus engaged in seeking to stimulate uterine 
contraction, he may direct the nurse or assistant in the use of other meas- 
ures. A full dose of ergot by the mouth, or better, hypodermically, 
because more quickly absorbed, should be given. In the presence of 
exhaustion, stimulation will be demanded: thirty drops to one drachm 
of sulphuric ether, one-fifteenth to one-twentieth grain of strychnine, or 
several drachms of brandy should be administered hypodermically. 
The child should at once be put to the breast, as nursing provokes 
uterine contractions. 

Even in the time of Hippocrates we find mention of the employment 
of various irritating chemical solutions and mechanical substances in the 
cavity of the uterus for the purpose of exciting uterine contractions and 
the arrest of bleeding. The introduction of ice into the uterus, while 
not now used as much as formerly, may be permitted, in the absence of 
other measures. A lump of ice the size of an egg is carried to the 
fundus of the uterus, and held in position till contraction occurs. The 
application of acetic acid, lemon juice, or alcohol in the uterine cavity is 
a powerful excito-motor. Either of these agents may be utilized by 
saturating a piece of sterile gauze with it and passing the gauze into 
the uterus. 

Penrose for many years advocated the employment of vinegar for the 



THE HEMORRHAGES. 531 

control of post-partal hemorrhage in the following manner : A clean 
piece of lint or gauze is saturated with vinegar, carried to the fundus of 
the uterus, and squeezed dry, the fluid running down over the walls 
of the uterus. A single application will often be followed by vigorous 
uterine contractions. If necessary, the process may be repeated two or 
three times. A lemon with the rind carefully pared off, and with 
numerous deep longitudinal slits to allow the escape of the juice, has 
been used in the same manner. A grave objection to these measures 
is the risk of infecting the uterus. 

Barnes recommends in extreme cases intra-uterine injections of a solu- 
tion of perchloride of iron. This procedure cannot be condemned too 
strongly. Not only is the woman exposed to the danger of pulmonary 
embolism, but a mealy mass of blood-clots is left in the uterus, which 
may serve as a nidus for the growth of putrefactive and pathogenic 
bacteria. 

The intra-uterine injection of hot sterilized water has recently come 
to be regarded as one of the most reliable means for the control of 
post-partal hemorrhage. In many of the Continental hospitals, and 
very largely in America, this method has become the routine treatment 
for uterine hemorrhage. The external genitals should be well smeared 
with carbolized vaseline or olive oil, to relieve pain from contact of the 
hot water with the skin. After removing the placenta and all clots 
from the uterus and vagina, a long douche-tube, preferably of glass and 
with openings only at the extreme end, is carried to the fundus. Several 
gallons of water are injected at a temperature of 48° C. (120° F.), or 
as hot as can be borne. The temperature of the water should not exceed 
125° F., lest the uterine muscle be paralyzed. Neither should it be below 
115° F., as merely lukewarm water favors hemorrhage. The tempera- 
ture should be determined accurately by a bath thermometer. Either a 
fountain or a Davidson syringe may be used, preferably the former. 

If the hemorrhage is not checked by this means, the injection should 
at once be repeated, after adding to the sterilized water enough pure 
acetic acid to make a 3 per cent, solution, 4 fluidonnces to the gallon. 
This is aseptic and is free from the dangers of vinegar or of the iron 
solutions. Its action is usually immediate and permanent. 

Simple measures failing, the uterus should be tamponed with strips 
of aseptic gauze ; this procedure, if properly carried out, will control 
a hemorrhage which resists all other measures. The method is as fol- 
lows : Three strips of plain sterilized gauze are cut, each three inches 
wide and about ten feet in length. The patient lies on her back across 
the bed, each thigh being supported by an assistant, and a vaginal douche 
of sterilized water is first given. The uterus is then irrigated. Each 
lip of the cervix is seized with vulsellum forceps or a tenaculum and 
drawn down toward the vulva. An assistant holds the tenacula. The 
operator now makes pressure on the fundus of the uterus with one hand, 
while with the other he grasps one end of a strip of gauze in a long 
uterine dressing-forceps and carries it to the fundus of the uterus. Suc- 
cessive layers of gauze are now deposited one on the other with moderate 
firmness until the uterus is completely filled. The ends of the gauze 
may be left projecting into the vagina, in which a little gauze may be 
loosely placed. If strict antiseptic precautions have been observed, the 



532 PATHOLOGY OF LABOR. 

tampon may safely be left in the uterus twenty-four hours. Renewal 
of the tampon is Very seldom required. The efficacy of the uterine 
tamponade may still further be increased by saturating the gauze with a 
strong alum solution. 

One of the most effectual measures for promoting energetic uterine 
contractions is faradization of the uterus. An electrode may be applied 
upon the abdomen over each side of the uterus or one upon the abdomen 
over the uterus, and the other over the upper sacral region. 

Treatment of Acute Anaemia. The principal measures available for 
restoring the volume of the circulatory flow are transfusion, auto-trans- 
fusion, subcutaneous, submammary, and intravenous injections of the 
normal salt solution, and rectal injections of this solution. 

Transfusion, or the introduction of blood from one person directly into 
the venous circulation of the patient, is a method formerly much in 
vogue, but now no longer practised. 

Auto-transfusion consists in forcing the blood from the extremities 
into the trunk and brain, and retaining it there by bandaging the extremi- 
ties. An Esmarch bandage may be applied to one arm, beginning at the 
fingers, and one to the opposite leg and thigh, beginning at the toes. 
Only two extremities should be constricted at once. These bandages 
may be left on twenty minutes to half an hour, and before their removal 
the opposite leg and arm should be bound in the same manner. By thus 
alternating the constriction, the danger of thrombosis and embolism is 
diminished. 

The use of the normal saline solution, introduced into the circu- 
lation either subcutaneously, directly into the veins, or by high rectal 
enemata, is the means now most generally relied upon. The normal 
saline solution consists of a solution of sodium chloride of the strength 
of seven-tenths of 1 per cent, in sterilized water; before using, it should 
be raised to a temperature of 37.5° C. (98° to 100° F.), and filtered 
through absorbent cotton. This solution may be prepared with sufficient 
accuracy by adding a teaspoonful of salt to a quart of sterilized water. 
Subcutaneous injections may be made with Munchmeyer's apparatus, or 
in the absence of this by means of an aspirating needle attached to a 
rubber tube having a funnel, fountain syringe, or a rubber bag at the 
other end. From one to three pints of fluid may be used. These injec- 
tions may be made beneath the skin of the abdomen, thigh, or back, 
or better, behind the mammary gland. High rectal enemata of the 
same solution may be given at frequent intervals and in as large quan- 
tities as can be retained. The patient should also be encouraged to 
drink freely of water, yet stomach absorption is usually in abeyance. 

Intravenous injections of the normal salt solution are given in the 
following manner : A funnel holding a quart, to which is attached a 
rubber tube terminating in a fine pointed glass tip or a metal canula, 
is filled with the previously prepared salt solution, which must be abso- 
lutely sterile and free from mechanical particles. The temperature of 
the solution should be about 37.5° C. (100° F.). The integument over 
the median basilic vein is now carefully disinfected, and the vein made 
promiuent by a snug bandage applied about the arm below the shoulder. 
An incision one inch in length is made parallel with and at one side of 
the median basilic vein. The vein is now freed from its attachment for 



THE HEMORRHAGES. 533 

a distance of half an inch with the handle of the scalpel. An aneurism 
needle threaded with a double silk ligature is introduced beneath the 
vein, the ligature cut, and the aneurism needle removed, One of the 
ligatures is drawn into the lower angle of the wound, the vessel ligated, 
and the ends of the ligature cut away. The constricting bandage above 
the field of operation may be removed. The second ligature is drawn 
upward toward the upper angle of the wound and one knot loosely 
taken. Having the canula or small glass tip now close at hand, with a 
gentle stream running, the vein is picked up with a pair of dissecting 
forceps, and an oblique upward slit made with the scissors, care being 
taken not to cat through the entire calibre of the vessel. The canula is 
cpiicklv introduced into the vein, the water running gently all the while, 
and is retained in position by drawing snugly the single knot of the 
ligature. The amount of solution introduced will vary from one to three 
pints, dependent upon the condition of the patient. The height at which 
the glass funnel is held will determine the force of the stream; usually 
three feet above the patient's body will be sufficient. When enough 
fluid has been introduced, as indicated by the radial pulse, the canula 
should be withdrawn, the ligature quickly tightened, a second knot taken, 
and the ends of the ligature cut away. The vein between the ligatures 
should now be completely divided, the skin incision closed by two or 
three sutures, and a dressing applied. 

Prolonged irrigation of the bowel with the hot saline solution at a 
temperature of 120° F. has recently been praised for the treatment of 
anaemia. A double-current canula is employed. As much as fifteen 
gallons of the salt solution may be used in this manner. Better results, 
it is claimed, are obtained than with subcutaneous injections. 

Convalescence from the anaemia resulting from severe post-partal 
hemorrhage is slow and tedious. The patient should not be allowed to 
nurse her child nor to assume the upright position for some time. A 
light but nutritious diet should be ordered. Alcohol in the form of light 
wine or beer may be advisable. A patient who has suffered from post- 
partum hemorrhage should not be allowed to sit up for at least four 
weeks after her confinement. The employment of iron in some form, as 
a tonic and hsematinic, is indicated. 

Secondary Post-Partum Hemorrhage. 

Hemorrhage from the uterine cavity occurring later than six hours 
after delivery is called secondary post-partum hemorrhage. Care must 
be taken not to mistake a profuse lochial discharge for true secondary 
hemorrhage. When in a given case bleeding occurs after the third day 
in any considerable quantity, a careful examination should at once be 
made, since the proper treatment to be adopted depends entirely upon 
an accurate determination of the cause of the hemorrhage. 

The causes of secondary hemorrhage, arranged as nearly as possible in 
the order of their relative importance, are as follows : Retention of por- 
tions of placenta and membranes ; clots in the uterine cavity ; irregular 
and inefficient uterine contractions ; displacements of the uterus ; dis- 
lodgement of thrombi from the uterine sinuses ; uterine fibromata and 
polypi ; constitutional causes ; overdistention of the bladder or rectum. 



534 PATHOLOGY OF LABOR. 

By far the most frequent cause of hemorrhage during the puerperal 
state is retention within the uterine cavity of fragments of the placenta 
or membranes. This retention may be due to the carelessness of the 
obstetrician, particularly in the conduct of the third stage of labor, or 
in the examination of the placenta. Often it is due to causes entirely 
beyond his control, such as adherent placenta, in which it is impossible 
to remove all placental tissue, or to placenta succenturiata or spuria. So 
commonly is secondary hemorrhage attributable to retained secundines 
that, in all cases in which profuse hemorrhage occurs after the third day 
following confinement, the obstetrician is justified in exploring the interior 
of the uterus at once, with full confidence that the cause of the. hemor- 
rhage will be found, To properly carry out the examination the patient 
should be anaesthetized. The cavity of the uterus may now be explored 
and fragments of placenta, membranes, or clots removed. The finger 
or, better, the blunt curette may be used. The interior of the uterus 
should be irrigated thoroughly with a hot weak antiseptic solution, 
as a 2 per cent, solution of creolin or a 5 per cent, solution of boric 
acid. If the hemorrhage persists, the curage or curettage must be 
repeated. 

Clots in the uterine cavity may give rise to hemorrhage if they are 
of sufficient size to interfere with the firm contraction of that organ. 
Irregular and inefficient contraction of the uterus favors the formation of 
these clots; rarely does it become necessary to remove them. While their 
expulsion may be attended with a gush of blood, the bleeding ceases 
as soon as the uterus is empty. 

Normally after labor the uterus is in a position of marked antever- 
sion. It may, however, from various causes, become displaced backward 
or upward. The cause of this condition may be an improperly applied 
abdominal bandage or pad, or the undue pressure of a greatly distended 
rectum or bladder. The result of such displacements is flexion of the 
uterine canal, with consequent accumulation of blood and lochia above 
the seat of flexion. The bleeding from this cause is more apt to be a 
persistent oozing than a free hemorrhage. The treatment consists in 
removing the cause and in irrigating the uterine cavity with hot steril- 
ized water. 

Hemorrhage due to displacement of thrombi in the uterine sinuses may 
rarely occur. If, after exploring the cavity of the uterus for clots or 
retained secundines, nothing is found to account for the hemorrhage, the 
possibility of dislodgement of thrombi should be suspected, and the bleed- 
ing controlled by packing the uterus with strips of iodoform gauze. 

Uterine fibromata and polypi may occasion secondary hemorrhage; 
their presence is recognized by a bimanual examination and by the 
sound passed into the uterus. The bleeding from a submucous fibroid 
can usually be controlled by small doses of ergot, opium, the local appli- 
cation of ice, or hot vaginal douches. The cause of the hemorrhage may 
be a small pedunculated polypus ; such a growth may easily be removed 
by torsion or the wire ecraseur. The full discussion of this subject 
belongs more properly to the gynecologist. 

Malignant disease of the neck or body of the uterus may very rarely 
be the cause of hemorrhage in the puerperium. In such cases hot 
vaginal douches may suffice for the time. 



THE HEMORRHAGES. 535 

It must not be forgotten that a puerperal hemorrhage may be due to 
inversion of the uterus. 

Various constitutional conditions and diseases may favor hemorrhage 
during the puerperal state. Sudden and profound mental shock, a 
debilitated condition of the system, as that dependent upon advanced 
syphilitic or tubercular disease, some of the acute infectious diseases, as 
scarlatina, diphtheria, and malarial poisoning, and finally, the influence 
of causes inducing uterine congestion, such as sudder, chilling of the 
surface of the body, too early assumption of the upright position after 
delivery, etc., sometimes give rise to uterine hemorrhage during conva- 
lescence from labor. 

A distended bladder or rectum after labor is liable to be attended 
with uterine hemorrhage, since by its reflex effect it inhibits uterine 
contractions. 



CHAPTER XXIII. 

ECLAMPSIA. 

Definition. By the terms eclampsia, puerperal eclampsia, and puerperal 
convulsions is meant, in modern medicine, an acute, morbid condition, 
making its advent during pregnancy, labor, or the puerperal state, which 
is characterized by a series of tonic and clonic convulsions, affecting first 
the voluntary and then the involuntary muscles, accompanied by com- 
plete loss of consciousness, and ending in coma or sleep. The disease 
may eventuate in death or recovery (Charpentier). 

Frequency. Eclampsia is most frequent in the later months of preg- 
nancy, less frequent in labor, and least frequent in the puerperium. Its 
occurrence is given by various authorities as 1 in 500 pregnancies; 1 in 
250 to 300; 1 in 350 to 500— a range of 0.2 to 0.4 per cent. It is 
said that the complication appears in 1 per cent, of all cases of albumi- 
nuria of pregnancy. Schauta places it at 0.25 per cent, of all pregnancies. 

Symptomatology. Symptoms of eclampsia may be classified as those of 
the prodromal period, or pre-eclamptic state, and those of the attack. In 
the latter, moreover, there are three'stages : (1) invasion; (2) tonic and 
clonic convulsions; (3) coma.* 

Prodromal Period, or Pre-eclamptic State. These symptoms 
are of great importance, for to the experienced they are a certain sign of 
an impending attack. As in epilepsy, a well-defined aura may give the 
warning. Following it, or occurring without it, there may be headache, 
tinnitus aurium, visceral disturbances, such as dizziness, amblyopia, amau- 
rosis, epigastric pain, digestive and nervous disturbances, and a feeling 
of general debility. These occur with a fair degree of constancy in about 
one-fourth of all cases of eclampsia. Less often symptoms of involve- 
ment of the brain occur, somnolence, stupor or insomnia, vertigo, vomit- 
ing, mental excitement, or despondency. All of them may subside, in 
which case appetite returns, perspiration and diuresis become more 
abundant, and the patient falls into refreshing sleep. Usually the issue 
is not so happy, and the premonitory signs, or pre-eclamptic state, after 
having existed for hours or days, give way to those of the 

Stage of Invasion. The eyes stare, the lids twitch convulsively, 
and the pupils, at first contracted to a pin-point, dilate widely. During 
the attack they are totally insensible to light. The face becomes cyanotic, 
and the muscles about the alee of the nose and the mouth jerk rapidly 
and convulsively. The mouth is drawn to one side, the head rotates, 
and the eyeballs are rolled up. This gives way to the 

Stage of Tonic and Clonic Convulsions. The movements, in 
the beginning confined to the head, extend to the neck, trunk, and 
extremities, rarely, however, passing to the legs. The neck is bent 
backward and fixed finally with the back in an opisthotonic curve. 
The arms are extended and rigid, the hands closed, with the thumbs in 

(536) 






ECLAMPSIA. 537 

the palms, and the knees flexed on the abdomen. The tonic convulsions 
involve the respiratory muscles, including the diaphragm. During the 
height of the paroxysm there may be one or two spasmodic respirations, 
although the chest muscles are strongly contracted. The tongue is par- 
tially protruded, and, being often bitten, the frothy saliva is tinged with 
red. Loss of sensation and consciousness is complete. Tonic convulsions 
last from ten to twenty seconds, and are succeeded by clonic spasms. 

As in the early part of the attack, the clouic convulsions begin in the 
face, which is horribly distorted, and extend over the body. Eespira- 
tion becomes irregular and noisy. The jaws open and close rapidly, and 
the tongue may again be bitten. As a rule, the body retains its previous 
position, but it may become necessary to hold the patient in bed. Toward 
the close of the attack respiration becomes full, labored, and stertorous. 
After one or two minutes the patient passes into the 

Stage of Coma. This period lasts about half an hour. During its 
continuance consciousness and sensation slowly return. If recovery is 
to take place, the woman falls into a deep sleep, and wakes to ask con- 
fusedly what has happened. This unconsciousness has led mothers to 
deny their offspring born during eclampsia. 

It is an exceptional occurrence for one attack only to occur. The first 
is usually followed at varying intervals by others. In case the seizures 
are uncontrollable and death is to ensue, the temperature rises progres- 
sively to 104° F. or more. The pulse is small, wiry, frequent, a semi- 
conscious state supervenes, and death takes place during this period or 
in an attack from pulmonary oedema, cerebral congestion, hemorrhage, or 
exhaustion, or some days later from an intercurrent puerperal affection. 

The Effect upon the Fcetus and Labor is almost constant. 
The former suffers decidedly — one attack may be sufficient to kill it. 
In twin pregnancy one or both may die. The child may survive several 
attacks. Winckel has observed a remarkable fact, that, if the foetus is 
killed and pregnancy not at once interrupted, the onset and course of 
labor may be free from convulsions. 

Pregnancy is apt to be terminated shortly, an accident easily under- 
stood in view of the shock, nervous disturbance, and uterine contractions. 
If the seizure occurs in labor, the pains are increased by the general mus- 
cular excitement, so much so that the child may be born before the 
physician is freed from his care of the mother. 

The kidneys are involved in about two-thirds of the cases of eclampsia. 
In 84 per cent, the urine contains albumin in quantity varying up to 
2.5 per cent, or more. Albuminuria, an important prodrome, increases 
with each attack, and decreases rapidly after their cessation. It usually 
contains sugar and formed elements, red and white corpuscles, and casts. 
In other words, symptoms of acute renal congestion are present. 

Etiology. The last word has by no means been spoken on this question, 
but this much may be stated with positiveness, that eclampsia does not 
always depend on albuminuria and kidney change, and, further, that 
albuminuria does not constantly accompany the convulsions. As may 
be supposed, many theories have been advanced to account for the phe- 
nomena, which, for a clear understanding of the subject, must be looked 
into and appreciated. 

The theory of Frerichs, that eclampsia is uremic, and that of Petroff 



538 PATHOLOGY OF LABOR. 

and Spiegelberg, that it is due to aixmionsemia, have been effectually dis- 
posed of by modern investigators, who have proved that there was abso- 
lutely no "retention of nitrogenous products in the important organs. 
Moreover, on recovery the amount of these products excreted was not 
excessive — in fact, was only equal to the amount secreted in starvation. 
Traube, Miirck, and Rosenstein have held that hydremia was the pre- 
disposing cause of eclampsia; but there stands in the way the fact that 
eclampsia has occurred where there was no hydremia, and in cases of 
pregnancy where there were uo contractions, the latter being the corner- 
stone of the theory, since it was held that the uterine contractions were 
responsible for increase of aortic pressure. Landois has claimed that 
hyperemia, particularly a venous stasis in the brain between the corpora 
quadrigemina and spinal cord, is likely to produce epileptiform convul- 
sions, while Galabin holds that eclampsia is due to anaemia of the cortical 
gray substance. Stumpf pins his faith to acetone as the exciting cause, 
since it has been found in the urine, and may be present in the exhala- 
tions. Its presence is not constant. 

Fleischer and others were led to the belief that the cause of eclampsia 
was to be found in the extractive materials present in the urine, and that 
when they were retained in abnormal amount in the body, convulsions 
occurred, by the following facts : (1) The symptoms of eclampsia resem- 
ble those produced by poisonous material circulating in the blood; (2) 
in eclampsia the amount of urine excreted is diminished (whether due to 
compression of the ureters or not, we cannot say); (3) the danger lessens 
and the tendency to convulsion diminishes from the moment the amount 
of urine passed in twenty-four hours is markedly increased. This is 
the theory of toxaemia, which has been ably supported by Bouchard in 
his experiments upon animals. His statement is that eclampsia is an 
intoxication closely resembling uraemia (the latter word being used in 
its broadest sense), " to which, in unequal portions, all the poisons intro- 
duced normally into the organism, or found therein physiologically, con- 
tribute when the quantity of poison formed or introduced in twenty-four 
hours can no longer be eliminated in the same time by the kidneys, which 
have become scarcely sufficiently permeable. " (The reader is referred 
for further elaboration of the theory to Bouchard's "Auto-intoxication," 
Chapter XV.). 

Schmorl 1 ascribes eclampsia to an intoxication by coagulation, pro- 
ducing ferments, which ferments originate in the placenta. 

Schmorl gives the following reasons for this conclusion : 

1. The clogging of the vessels, reported by himself, JGebs, and 
Lubarsch, which is undoubtedly of primary origin, is like those throm- 
boses which we observe in man and animals when coagulation-producing 
ferments are introduced into the blood. 

2. Klebs' opinion that the coagulation-ferments are produced by the 
destruction of the embolic liver cells is wrong. 

3. According to Schmorl' s, Lubarsch' s, and Jung's investigations, 
placenta-cells pass into the blood regularly, which cells, as experiments 
on animals show, have a tendency to provoke coagulation, at least when 
present in large number. 

1 Path. Theses, Halle, 1892, vol. ii. p. 155. 



ECLAMPSIA. 539 

Schmorl, 1 in another place, ascribes an important role to this throm- 
bosis of the blood, stating that the thrombosis may be embolic in origin, 
but most often is primary. 

In still another place 2 he states that the parenchymatous cells entering 
the circulation interfere with the chemical composition of the blood. . . . 
That in eclampsia coagulation of the blood occurs owing to parenchyma- 
tous embolism. He claims to be able to demonstrate in most cases of 
eclampsia the presence of thrombi in the arteries, and more especially in 
the veins. According to SchmorPs opinion, a toxic substance contained 
in the blood is responsible for eclampsia; experiment has shown that 
dying cells produce a ferment which coagulates blood, but he thinks 
that our knowledge about the metabolic process in the placenta is not 
enough to place the origin of this ferment in this organ. 

Lubarsch 3 cannot accept SchmorPs opinion that the role of the liver 
cells in eclampsia is secondary. . . . From experiments and obser- 
vations he believes that, owing to the penetration of liver cells into the 
blood current, a coagulation-producing ferment is produced. Lubarsch 
agrees w^ith Schmorl that in some cases of eclampsia the thrombi are of 
primary origin, entirely independent of the liver cells. He nevertheless 
sees in the liver cells the factor for the production of coagulation and 
thrombosis with all its consequences. He believes the liver-cell embol- 
ism plays an important part in eclampsia, and that attacks due to liver- 
cell embolism will expose the organism to the formation of more thrombi 
and infarctions. He further believes that embolisms due to cells are not 
the cause of diseases combined Avith convulsions, but that they are the 
consequence of the convulsions. 

According to Lubarsch 4 the liver-cell embolism is either of a traumatic 
nature or due to toxic infection, and appears to take place in all regions 
where, owing to the presence of necroses and hemorrhages of the liver, 
the tissues are subjected to increased pressure. 

Volhard, 5 F., observed that the urine passed after an eclamptic attack 
was increased in toxicity, was imbued with specific properties, producing 
during life thrombosis when injected into the veins. This confirms 
SchmorPs statement that eclampsia is an auto-intoxication produced by a 
coagulation-producing poison. This substance, according to Volhard, 
does not injure the epithelium of the kidneys directly, but indirectly by 
clogging the nutritive vessels. 

Ludwig and Savor 6 consider eclampsia as a process due to auto-intoxi- 
cation by a ferment which is the product of metabolic processes, and 
masked in the organism during pregnancy, owing to the derangements in 
the metabolic processes. The action of the ferment is expressed by the 
symptoms of eclampsia. The removal of the ferment by the kidneys 
takes place after the convulsion. Whether this ferment is due to the 
lesions in the liver, or presents a connective link in the synthesis of 
urine, further investigation alone can determine. 

1 Path, anatomische Untersuchungen liber puerperal Eclampsie. Leipzig, 1893. 

2 Pathologische anatomische Befunde bei Eklampsie. Trans, of the German Gynecol. Soc, Leip- 
zig, 1891, p. 179. 

3 Zur Lehre von der Parenchym. Embol. Fortsch. d. Med., 1893, vol. xi. p. 806. 

4 Die puerperal Eklampsie. Lubarsch u. Ostersay, 1898, vol. i. p. 120. 

5 Experimental und kritische Studien zur Pathogenese der Eklampsie. Monatsch. f. Geb. u. Gvn., 
1897. Bd. v., H. v. 

G Experiment. Studien zur Pathogenese der Eklampsie. Monatsch. f. Geburts. u. Gynaekol., 1895, 
Bd. i., H. v., p. 447. 



540 PATHOLOGY OF LABOR. 

This is where we stand to-day in regard to the etiology of eclampsia. 
As to the nature of the poisons, we are much in doubt, even if we accept 
all of Bouchard 7 s statements. According to his experiments, urea contrib- 
utes one-eighth of the total toxicity of eliminated urinary products, color- 
ing matters, and other substances fixed by charcoal (leucin, tyrosin, etc.), 
two-fifths, the remainder being made up of mineral salts, chiefly of potas- 
sium. Since these statements are based on animal experimentation (other 
than human), they are to some extent unreliable. This short review of 
the theory of toxaemia explains the reason for the existence of many of 
the exciting and predisposing causes of eclampsia — e. g., any interference 
with the permeability of the renal filter. 

Predisposing Causes may be classed under three headings : (1) All 
chronic and acute forms of kidney disease, all nephritis, old and recent 
inflammatory changes, the recent u kidney" of pregnancy, which result 
in failure of elimination, hydraemia, albuminuria, and oedema. (2) 
Long-coutinued and marked retention of urine, particularly that pro- 
duced by pressure on the ureters. This pressure may be exerted by (a) 
an abnormally enlarged uterus, as in twin pregnancy, hydramnios, etc. ; 
(6) small pelves; (c) large foetus or foetal head. In proof of this cause 
stand the striking figures of the occurrence of eclampsia in 11 per cent, 
of multiple as against the 1.1 per cent, of single pregnancies. (3) Very 
young or very old primiparae are particularly prone to attack on account 
of their rigid muscles and the lack of room in their pelvic and abdominal 
cavities. The proportion of eclamptic primiparae to multipara? is three 
to one (Schauta.) 

Exciting Causes, acting in the presence of predisposition, may lie in (1) 
sudden, partial, or complete suppression of urine; (2) constipation; 
(3) painful uterine contractions, an unyielding external os or introitus 
vaginae in primiparae; (4) prolonged and exhausting efforts at expulsion; 
(5) profound emotion. The eclamptic convulsion once established, the 
slightest shock, external or internal, is sufficient to determine a par- 
oxysm. 

The Pathology of the condition is, as may readily be imagined, more 
than obscure. Post mortem the changes are an anaemia of the organs 
generally, a congestion of the cerebral cortex, occasional slight hepatic 
apoplexies, and a fluid condition of the blood. The chief changes, dimin- 
ished urinary toxicity and corresponding increase in amounts of circu- 
lating poisons, are rather to be found intra vitam than after death. 

Diagnosis of puerperal eclampsia, at first sight, appears to be simple, 
but to make a careless diagnosis is to invite a serious mistake sooner or 
later. The mere concurrence of a convulsive seizure with pregnancy or 
the puerperium does not per se warrant the conclusion that it is eclamptic. 
There are four conditions to which the pregnant parturient or the puer- 
peral woman is subject which may be mistaken for eclampsia. They 
are (1) epilepsy, (2) hysteria, (3) apoplexy, and (4) meningitis. 

Epilepsy is distinguished by the history of former and repeated attacks, 
by the presence of urine, normal in amount, free from albumin and casts 
(except in intercurrent nephritis), by coma more complete, by the absence 
of oedema and of prodromes, saving the usual aura. The epileptic falls 
suddenly with a sharp cry. Hysterical patients are conscious, as a rule, 
in the attack, the muscular contractions are less severe, there is never a 



ECLAMPSIA. 541 

coma. They scream, laugh, or cry, oedema is not present, and they pass 
large quantities of clear, pale urine. Here, also, a history of previous 
attacks may be elicited. Apoplexy is rare in pregnancy. It comes on 
suddenly without prodromata. Coma supervenes early. Convulsions 
are absent, aud paralysis evident. Meningitis is even more rare. The 
history will aid materially in forming an opinion. The convulsions are 
local as opposed to general in eclampsia, and they increase in severity by 
easy stages. Fever always precedes their appearance. 

In all cases of doubt careful attention should be paid to the urine, and 
its quantity, and the presence of albumin, sugar, blood, and casts thor- 
oughly investigated. With these aids to the clinical picture, the attend- 
ant should have little difficulty in forming a correct opinion. 

Prognosis. Puerperal eclampsia is a most serious affection. Even at 
the present day the maternal mortality is 30 per cent., that of the child 
50 per cent. The pregnant woman who is suffering from decided symp- 
toms of toxsemia, albuminuria, and the quantity of whose urine is daily 
diminishing, is in great danger of an attack. As the albumin increases 
and the quantity of water passed in the twenty-four hours diminishes, 
the danger becomes more imminent. The peril becomes more remote as 
the converse takes place. Urea, as to amount excreted, is a better guide 
in prognosis, as shown by Bouchard and Davis, than albumin. The 
latter found toxic symptoms to diminish with its increase. The earlier 
in pregnancy the seizure occurs the worse the prognosis. Schauta has 
proved time and again that all disturbances, even those of the kidneys, 
decline after the death of the child; consequently the sooner it dies in 
repeated attacks the better the prognosis. An early occurrence of pro- 
fuse sweating is an encouraging sign. Prognosis is most unfavorable 
when the attacks occur in pregnancy, when they succeed each other 
rapidly, and become progressively more severe, and when they have lasted 
for some time before aid is secured. Chloroform treatment has lessened 
mortality in these cases. To sum up, prognosis is favorable when — 

1. The attacks are infrequent and mild. 

2. The child dies. 

3. The patient is conscious in the intervals. 

4. There is a small amount of albumin. 

5. A fall of temperature occurs. 

6. The attacks occur late in labor or during the puerperium. 
Prognosis is unfavorable when opposite conditions prevail. The child 

born of an eclamptic mother has a diminished vitality, and often dies in 
the first twenty-four hours. 

The causes of death in the mother are exhaustion, apoplexy from forcible 
rupture of the cerebral vessels, asphyxia due to spasm of the muscles of 
the glottis and of respiration, pulmonary and cerebral oedema, the result 
of serous effusion from distended capillaries, cerebral congestion, of which 
coma is a symptom, and paralysis of the heart. The last, when it occurs 
in the general spasm, causes instant death. The causes of the child's 
death are the mother's convulsions and the pressure exerted by them, 
asphyxia from compression or oedema of the placenta, or the excess of 
carbon dioxide in the blood, possibly direct poisoning by the toxic mate- 
rials in the maternal circulation. 

Treatment. Granted the contention, which, if not absolutely correct, 



542 PATHOLOGY OF LABOR. 

is at least the best theory of etiology we have to-day, that eclampsia is 
the result of toxasmia, then of the two treatments of eclampsia, prophy- 
lactic and curative, the former is by all odds the more important, since 
the seizure is generally preventable. This is an opinion which is shared 
by many prominent American as well as foreign obstetricians, 

(a) The Preventive Treatment. What symptom or sign, or 
what combination of symptoms or signs, is at our disposal for the 
recognition of the pre-eclamptic state in time to prevent the subsequent 
eclamptic convulsions ? 

The symptoms of the state preceding an eclamptic attack include a 
rapid pulse, accompanied usually by high arterial tension, loss of appe- 
tite, gastric and intestinal disturbances, headache, lassitude mental and 
physical, a gradual or rapid diminution of all the excretions, both liquid 
and solid — in a word, what one would expect to observe from the intro- 
duction or retention in the blood of some toxic material. 

Aside from the direct examination of the blood itself, the condition of 
the urinary secretion offers us the most convenient physical sign or clin- 
ical index of this pre-eclamptic state. The amount of urine passed in 
twenty-four hours is not always a reliable guide of kidney failure. Albu- 
minuria, as is well known, may be absent before, during, and even after 
an eclamptic seizure. The amount of urea excreted is a far better guide, 
as has been shown by Bouchard, of Paris, in the non-pregnant condition, 
and recently by Dr. E. P. Davis, of Philadelphia, in pregnancy; for 
the latter found that when urea fell to 1.5 per cent, stimulation of the 
excreting processes resulted in distinctly favorable results in all cases 
in which toxic symptoms were previously present. It is not to be 
inferred from this that urea causes the convulsions, for large quantities 
of urea may be injected into rabbits without producing toxic symptoms. 
Indeed, Bouchard found that bile had nine times the toxic power of urea. 
It is generally accepted that the diminution in the amount of the urea 
excreted indicates kidney inadequacy; but it is not always a reliable 
guide. There are other substances in the urine with as great or greater 
poisonous qualities. Urea may be found in sufficient quantity and an 
eclamptic attack occur. Bouchard determined the toxicity of the urine 
by injections of the same into the circulation of rabbits. His experi- 
ments show that the normal healthy urine is toxic in the proportion of a 
certain unit per kilo by weight of the rabbit. In kidney insufficiency, 
when some poison or poisons are retained in the circulation, the toxic 
properties of the urine diminish, and. it requires more of the urine to the 
kilo by weight of the rabbit to produce toxic symptoms in the animal. 
This gives us a delicate test for determining kidney inadequacy in doubt- 
ful cases. Bouchard's experiments further show that in renal insuffi- 
ciency the poisons retained in the patient's blood arise from: 

1. Food, especially nitrogenous food, as muscle, and food containing 
the salts of potassium. 

2. Bile. 

3. Putrefaction in the intestines, and absorption of its products. 

4. Toxic materials constantly being produced by the metabolism of 
all the cells of the body. 

To this last may be added the metabolism of the fcetal tissues, as this 
greatly increases the toxic material in the mother's blood, for, clinically, 



ECLAMPSIA. 543 

it is a familiar fact that when the fcetus dies in utero, or is delivered in 
the ease of a living child, the eclamptic seizures usually cease. 

Again, WinckePs observation, that in twin and triple pregnancies 
there is a greater predisposition to eclampsia, has been verified by others. 
Moreover, the tendency to eclampsia becomes greater proportionately 
with the advance of gestation and the consequent increase of foetal metab- 
olism. 

Further, we know that the maternal mortality diminishes progressively 
from the ante-partum to the post-pa rtum states, namely, that it is greatest 
when eclampsia sets in during pregnancy, is less during labor, and lowest 
of all when the attack occurs for the first time after the birth of the child. 
Thus, the mortality during eight years at the Boston Lying-in Hospital, 
as has been shown by Green, 1 was : ante-partum eclampsia, maternal 
mortality, 46 per cent. ; foetal mortality, 69 per cent. Intra-partum 
eclampsia, maternal mortality, 25 per cent. ; foetal mortality, 25 per 
cent. Post-par turn eclampsia, maternal mortality, 7 per cent. 

Our present knowledge of the causation of puerperal eclampsia, meagre 
though it be, furnishes us, if not with the key to the successful preventive 
treatment of the condition, still with a working hypothesis, namely, the 
early recognition of the pre-eclamptic state. To accomplish this some- 
thing more than a perfunctory monthly or bimonthly examination of the 
urine for the presence of albumin is called for, since non-albuminuric 
eclampsia occurs in from 9 to 16 per cent, of cases, and it would appear 
to be quite as fatal as an eclampsia accompanied by albuminuria, if not 
more so. Something more is demanded than the late recognition of 
renal insufficiency, as it shows itself in a marked diminution in the quan- 
tity of urine, specific gravity of the same, and amount of urea excreted. 

When obstetricians shall accustom themselves to watch their cases of 
pregnancy, not only for the physical signs of pronounced renal inade- 
quacy as an index of an approaching eclamptic attack, but also for the 
general symptoms of the overcharging of the blood with toxic material 
— as high arterial tension, headache, gastric disturbances, physical and 
mental lassitude — and further for failure of the bowels, liver, skin, and 
lungs properly to perform their functions, and intelligently treat the 
same, then, and then only, shall they have done their whole duty by their 
patient, and done all in their power to correct the pre-eclamptic condition 
and avert an impending eclampsia. 

The writer's line of treatment of this pre-eclamptic state may be formu- 
lated somewhat in the following manner : 

1. Reduce the amount of nitrogenous food to a minimum. 

2. Limit the production and absorption of toxic materials in the intes- 
tines and tissues of the body, and assist in their elimination by improving 
the action of (I) the bowels, (2) the kidneys, (3) the liver, (4) the skin, and 
(5) the lungs. 

3. If necessary, remove the source ofihefostal metabolism and of periph- 
eral irritation in the uterus by the emptying of that organ. 

The first indication — reduction of the amount of nitrogenous food to 
a minimum — can best be fulfilled in an exclusive milk diet, to which, as 
the symptoms subside or disappear, can be added fish and white meats. 

1 Green: "Puerperal Eclampsia; Experience of the Boston Lying-in Hospital in the Last Eight 
Years," American Journal of Obstetrics, 1893, xxviii. 18-44. 



544 PATHOLOGY OF LABOR. 

It is not only safer, but less trying to the patient, to commence with an 
absolute milk diet, than to compromise and afterward be compelled to 
cut off all but the milk. For the second indication — that of elimination 
— an abundant supply of pure air and water must be assured. This 
may be assisted by moderate exercise or light calisthenics, or massage, 
in certain instances. For the bowels, the writer advocates daily doses of 
colocynth and aloes at bedtime, followed by a saline in the morning. 
For the liver an occasional dose of calomel and soda at bedtime, followed 
in the morning by one of the stronger sulphur waters, as Rubinat, Villa- 
cabras, or Birmeustorf. Increased diuresis is secured by maximum doses 
of glonoin. The action of the skin is encouraged by encasing the body 
in wool or flannel underclothing, by massage, by the warm bath, hot 
bath, hot pack, or hot-air bath, according to the urgency of the case. 

It is well in instances of eliminative insufficiency to give at bedtime 
twice weekly, or more frequently, if necessary, a tablet composed of 
calomel, digitalis, and squill, each one grain, and muriate of pilocarpine, 
one-twentieth of a grain. This is followed in the morning by a full dose 
of Yillacabras water. A decided diaphoretic-diuretic action follows the 
administration of such a combination, with the additional prompt action 
upon the liver and intestines as well. So of the five eliminative pro- 
cesses, four are stimulated to more energetic action by its use. 

The fact that jaborandi has been practically abandoned as a diaphoretic 
in the presence of an eclamptic attack is no good reason for prohibiting its 
use in this, the pre-eclamptic state, in the absence of pronounced cardiac 
disease, and the writer advocates its use for its diaphoretic and diuretic 
actions. 

Finally, when exercise cannot be taken and an abundant supply of 
fresh air is wanting, oxygen inhalations will prove of service. Some 
preparation of iron will also be called for, as the tincture of the chloride, 
or Basham's mixture. 

This, then, is the general hygienic and medicinal treatment of the pre- 
eclamptic state. No hard and fast rule can be laid down. Every case 
must be treated on its merits. In one a restricted diet and mild stimu- 
lation of the renal and intestinal functions is sufficient, and the patient 
may be allowed to be about, and even exercise in the open air, her skin 
being protected from sudden changes by being incased in wool or flannel. 
Other more pronounced cases of eliminative insufficiency must be kept 
absolutely quiet in bed upon an exclusive milk diet, and the stimulation 
of all the eliminative organs must be resorted to, to remove the symp- 
toms of impending eclampsia. 

But it must be kept ever before us that the hygienic and medicinal 
treatment is only of secondary importance to the milk diet, and that the 
latter is the foundation of the preventive treatment of puerperal eclamp- 
sia. Given a case in which, in spite of an exclusive milk diet and the 
vigorous stimulation of the five excretory outlets already mentioned, the 
symptoms and signs of the pre-eclamptic condition continue or at any 
time become urgent, the indication is to induce abortion or premature 
labor artificially. 

It is difficult to undersand the position of those authorities (notably of 
the British school of midwifery) who advise against inducing labor in 
the presence of urgent symptoms of the pre-eclamptic state. 



ECLAMPSIA. 545 

The arguments that by the methods usually in vogue induced labor 
increases reflex excitability and precipitates convulsions; that by the same 
methods, because of the time necessary to remove the barrier of the cer- 
vix, the patient's fate is sealed before the delivery is effected; and, more- 
over, that the onset of labor increases the danger to the patient, are good 
ones and demand attention. 

In answer, it may be said that methods of terminating the pregnancy 
recommended here need not increase reflex excitability, and, if per- 
chance they do, the excitability is readily controlled for the time neces- 
sary to accomplish our ends; that the time necessary is, in most cases, 
very short; and, finally, that to-day the onset of labor and the termina- 
tion of pregnancy may be practically brought about at one and the 
same time, and there is thus no prolonged or tedious labor to react 
unfavorably upon the patient. 

The objection raised by Byers (International Congress of Obstetrics 
and Gynecology, Geneva, September, 1896) that induced labor, because 
of the necessary manipulation, increases the risk of sepsis, should not 
deter the modern obstetrician from performing the operation when he 
knows that he is surgically clean. 

Charles, of the Liege Maternity, reported, at the International Con- 
gress of Obstetrics and Gynecology in 1896, in favor of induced labor 
when treatment fails or the symptoms become urgent in the pre-eclamptic 
state. His statistical table shows that every mother recovered and 75 
per cent, of the children were saved. 

The writer recommends a rapid manual dilatation of the os in these 
cases, but only after the cervical canal is in a condition favorable for its 
safe performance. Moreover, he would insist upon a complete dilatation 
of the os before delivery is undertaken. 

(6) The Curative Treatment. In the presence of an eclamptic 
attack we face a desperate condition. The latest statistics from various 
parts of the world still place the maternal mortality at from 25 to 35 per 
cent. As long as the pathology of eclampsia remains obscure there can 
be no rational curative treatment of the condition. Experience does not 
permit of recommending any single treatment. Many subjects recover, 
no matter what the treatment, many die in spite of treatment, and others 
do well without any treatment at all. No single treatment can be advo- 
cated; each case must be managed according to the indications present. 
Not a single but a combined treatment promises best for saving the lives 
of mother and child in the event of an eclamptic seizure. For this 
combined treatment three indications are offered, as follows : 

1. Control the convulsions. 

2. Empty the uterus under deep ancesthesia by some method that is rapid 
and that will cause as little injury to the patient as possible. 

3. Eliminate the poison or poisons which we presume cause the convul- 
sions. 

Although these indications are named in the order of their importance, 
still they may all be carried out at the same time. In another class of 
cases we fulfil the first and third, and wait for a suitable moment to carry 
out the second. The third indication — elimination — should really go 
hand-in-hand with the first two and be put into action at one and the 
same time with them. 

35 



546 PATHOLOGY OF LABOR. 

Control the convulsions. The four medicinal means most certain and 
safe as antieclamptics are chloroform, morphine (hypodermatically), verat- 
rum viride, and chloral hydrate, the latter alone or combined with sodium 
bromide. 

The writer's preference is for chloroform, veratrum viride, and chloral, 
in the order named. Until three years ago he used morphine freely in 
eclampsia, but has since abandoned its use almost entirely, as it appar- 
ently prolongs the post-eclamptic stupor and increases the tendency to 
death during coma by interfering with the eliminative processes. 

Chloroform is of all agents the most reliable for immediate control of 
the convulsive seizures. 

Second only to chloroform in value is veratrum viride. Provided the 
pulse be strong as well as rapid, it is the most certain means at our com- 
mand for temporarily, and even permanently, controlling the convul- 
sions. When the pulse is weak morphine hypodermatically, chloroform 
by inhalation, and chloral by rectum, with stimulation, if necessary, may 
be substituted. 

Veratrum viride reduces the pulse-rate, and convulsions are practi- 
cally unknown with a pulse-rate of 60 or under; it reduces the tem- 
perature; it relaxes and renders more yielding the rigidity of the cervical 
rings; it causes prompt diaphoresis and diuresis, so that it aids not only 
in the fulfilment of our first indication, the control of the convulsions, 
but in the third, the elimination of an unknown poison as well. 

From ten to twenty minims of the fluid extract of veratrum viride, 
given subcutaneously, should, as a rule, be the initial dose. Ten minims 
more may be given in the same manner every half-hour till the pulse 
remains below sixty to the minute. The patient should be kept in a 
recumbent position while under the influence of the veratrum. Tumult- 
uous action of the heart is likely to supervene on assuming the erect 
position. Vomiting and collapse, should they ensue, are readily con- 
trolled by whiskey or by morphine. 

The last resort for controlling the convulsions is the prompt evacua- 
tion of the uterus. It may be added, however, that cold applications, 
such as ice-bags to the back of the head and neck, have a decided effect 
in controlling and in warding off convulsive attacks. 

Empty the uterus under deep ancesthesia by some method that is rapid 
and that will cause as little injury to the woman as possible. Those who 
follow the teachings of Charpentier, of France, and Winckel, of Ger- 
many — namely, that the uterus in eclampsia should be left alone except 
after full dilatation of the os, as the irritation of inducing labor or arti- 
ficially dilating a cervix precipitates convulsive attacks — will, doubtless, 
see many cases lost that could by prompt and intelligent measures be 
saved. It would appear from careful observation that the danger is 
practically over in some 90 per cent, of cases the moment the uterus is 
emptied, if accomplished early in the attack. Not that by this means 
the convulsions always cease, but they become less dangerous, and the 
case becomes one of post-partum eclampsia, in which the mortality, as we 
have stated, is only 7 per cent. 

Although one can scarcely find an authority to-day who absolutely 
rejects local interference in the presence of ante-partum or intra-partum 
eclampsia, yet authorities differ widely as to the extent to which such in- 



ECLAMPSIA. 547 

terference shall be carried. Charpeutier, in 1892, as the result of an ex- 
haustive analysis of four hundred and fifty-four cases of eclampsia, and 
again in 1896, as the result of further observation, practically arrives at 
the same conclusion, namely: 

1. That labor should be waited for and terminated naturally whenever 
possible. 

2. That induced labor should be reserved for exceptional cases in 
which medical treatment has entirely failed. 

3. That interference should be delayed until the cervix is dilated or 
dilatable, so as to avoid danger to the mother; that in eclampsia Cesa- 
rean section, manual dilatation of the cervix, and especially deep incisions 
of the cervix are absolutely unjustifiable. 

On the other hand, it would appear from the literature of the last five 
years, and from the reports of the International Congress at Geneva, 
September, 1896, that the weight of medical opinion is in favor of 
emptying the uterus in as short a time as possible in instances of eclamp- 
sia, whether the attack occurs before or during labor, although there is 
a wide range of opinion as to the means to be employed. In the second 
stage of labor, after dilatation has been secured, all authorities are agreed 
that the immediate emptying of the uterus is indicated and is to be 
performed promptly; the indication under such circumstances is readily 
carried out without additional danger to mother or child. In pregnancy 
and the first stage of labor the undilated cervix is the barrier to imme- 
diate delivery, and it is here that obstetricians differ so widely as to the 
best method of procedure. An expectant or palliative treatment means 
almost certain loss of the child, and something like one-third of the 
mothers are lost. On the other hand, the child is saved and the mother 
is practically safe, as far as the eclampsia is concerned, if the uterus is 
immediately emptied by appropriate surgical means. 

During pregnancy and the early part of labor four procedures are 
offered for rapidly emptying the uterus, viz. : 

1. Cesarean section. 

2. Mechanical dilatation of the cervix (various methods). 

3. Deep incisions which at once completely remove the barrier of the 
cervix. 

4. Combined mechanical dilatation and deep cervical incision. 

The first method, Cesarean section, for the relief of eclampsia still 
carries with it a high mortality (36.26 per cent., according to Charpeu- 
tier' s figures); moreover, there are many objections to its employment, 
as the uterine atony and hemorrhage, the irritation of the uterine and 
abdominal scars and of the curative peritonitis about the uterine sutures, 
all of which are to be avoided as exciting causes of subsequent eclamptic 
seizures. 

The second method, the mechanical dilatation of the cervix and the 
immediate extraction of the foetus, appears to be the popular method of 
the day. Properly performed the method is safe and efficient. Before 
dilatation is well advanced, however, from forty minutes to an hour and 
a half is necessary safely to carry it out, and certain conditions of the 
cervix, even in this time, refuse to yield to manual dilatation or result in 
lacerations into the lower uterine segment. 

The third method of delivery, by deep cervical incision, offers a sur- 



548 



PATHOLOGY OF LABOR. 



gical means for emptying the uterus in from five to ten minutes, pro- 
vided the supravaginal portion of the cervix has disappeared or is made 
to disappear by appropriate means. 

The fourth or combined method is a combination of the second and 
third methods, and is applicable to cases in which the supravaginal por- 
tion of the cervix is still present and rapid emptying of the uterus is 
demanded. Here mechanical dilatation of the os until the internal os 
has been caused to disappear is made use of, and the dilatation then in 
an instant completed by the incisions. 

The third method and its modification, the fourth, are comparatively 
new, and we have few statistics as to the results of the operation. A 
rapid manual dilatation of the os and subsequent extraction of the foetus 
will fulfil the indications in most cases; but unless this can be intelli- 
gently carried out, with a due appreciation of the mechanism of dilata- 
tion, especially in primiparae, a purely expectant treatment will give 
better results. Unfortunately, puerperal eclampsia is four times more 
frequent in primiparse than in multipara?, although, on the other hand, 
the mortality is greater in the latter. 



Fig. 341. 




IN. OS. 



EX. OS. 



Cervix in latter part of gestation or at beginning of labor. Vaginal and supravaginal portions 

of cervix unchanged. (From Edgar.) 
v. Cuff of vagina, ex. os. External os and infravaginal portion of the cervix. c.v.J. Cervico- 
vaginal junction, s.v.c. Supravaginal portion of cervix, in. os. Internal os. l. tj. s. Lower uterine 
segment. 



The cervix uteri is composed of constricting and dilating muscle, and, 
while it is true that the first convulsions usually induce labor, still the 
resulting asphyxia exerts a marked constricting action upon the body of 
the uterus and cervix, which is especially marked at the internal ring 
of the os. Therefore, any method of rapid manual dilatation of the os 
that is undertaken before the internal os has been made, partially at least, 
to disappear is attended with great danger of uterine rupture (Figs. 341, 
342). This is especially true in primipara?, in whom the supravaginal 
portion of the cervix obtains late in pregnancy and even up to the begin- 



ECLAMPSIA. 



549 



ning of labor (Fig. 341). We believe a warning should be sounded 
against the careless undertaking of rapid manual dilatations of the os, 



Fig. 342. 




IN. OS 



Lower uterine segment during labor. (From Edgar.) 
v. Cuff of vagina, ex. os. External os, infravaginal portion of cervix has disappeared, c. v. J. Cer- 
vico-vaginal junction, s. v. c. Supravaginal cervix, small portion only remaining, in. os. Internal 
os. L. r. s. Lower uterine segment. 

particularly in eclampsia. Uterine rupture and death have been the 
outcome. Moreover, undue shock has resulted from the dragging of a 

Fig. 343. 




IN. OS. 



EX. OS, 



Lower uterine segment during labor. Os uteri in progress of dilatation. Supravaginal and infra- 
vaginal portions of the cervix have disappeared. Os admits one finger. (From Edgar.) 
v. Cuff of vagina, ex. os. External os. in. os. Internal os. u. v. J. Utero- vaginal junction. 
L. u. s. Lower uterine segment. 



foetus through an imperfectly dilated os, to say nothing of the loss of 
the child. 

In placenta prsevia the hemorrhage and the resulting anaemia of the 



550 



PATHOLOGY OF LABOR. 



lower uterine segment and cervix render these parts more readily dilat- 
able. In eclampsia the reverse obtains, as has been already hinted. 
Hence it is that in eclampsia in instances in which the internal ring of 
the os has been drawn up into the body of the uterus (Figs. 342, 343), 
and the external ring remains rigid and tense, particularly in primiparse, 
and there is urgent need of rapidly terminating the labor, we prefer four 
clean incisions extending from the edge of the os to the utero- vaginal 
junction, in order to save the patient from the greater dangers of rapid 
manual dilatation. 

Fig. 344. 




Bimanual dilatation of the parturient os. (From Edgar.) 
Os two-thirds dilated. Entire effacement of the internal os. Compare Fig. 343. 

In the second place, a warning is not out of place against the prema- 
ture extraction of the foetus before full dilatation has been secured and 
the external ring of the os paralyzed. Premature extraction, under such 
circumstances, has, to the writer's knowledge, resulted in many unneces- 
sary and dangerous lacerations of the lower uterine segment and an 
increase of the mortality for the child and mother. 

Elimination of the poison or poisons ichieh are presumed to cause the 
convulsions. To eliminate toxic materials from the blood and tissues 
the following measures may be relied on. It is essential, however, to 
rely not upon one but upon all the eliminative organs of the body, 
and that the fulfilment of this third indication in the treatment of 
eclampsia should go hand-in-hand with the two already mentioned. 



ECLAMPSIA. 



551 



To this end catharsis must be secured as early and as promptly as possi- 
ble by the administration of croton oil, compound jalap powder, or calo- 
mel, followed by salines and high enemata of sulphate of magnesium. 
In the coma or post-eclamptic stupor of the condition the writer has 
relied mainly upon the repeated administration of concentrated solutions 
of sulphate of magnesium or Villacabras water, by means of a long rectal 
tube high up in the descending colon. The hypodermatic administration 
of magnesium sulphate has been found too slow and uncertain to be of 
any use. Diuresis is obtained by dry or wet cups over the kidneys, 
followed by hot fomentations. The value of glonoin as a diuretic and 
antieclamptic, the latter by reducing the arterial tension, cannot be over- 
estimated. Second only in value to glonoin is veratrum viride. It is 
to be given at this time for the same reasons and for the same results as 
when it was administered in the pre-eclamptic condition. Diaphoresis 
is encouraged by means of the hot-air bath or the hot pack, the writer's 
preference being for the former. Pilocarpine as a diaphoretic in the 

Fig. 345. 




Dangers of a rapid breech extraction through an imperfectly dilated os. External os not fully 
dilated or paralyzed. Traction on the legs results in extension of the head and both arms. (From 
Edgar.) 

presence of an eclamptic attack should be utterly rejected, because of the 
danger of oedema of the lungs and glottis which it may produce. These 
conditions may follow promptly upon its administration. The drawing 
off of large quantities of toxic liquids in the form of blood or serum, 
by means of venesection, catharsis, diaphoresis, diuresis, followed by the 
replacement of the same by intravenous, stomachic, rectal, or hypodermatic 
means, causing a washing or disintoxication of the blood and tissues, as 
it were, has thus far proved of doubtful value. On the other hand, the 
prolonged irrigation of the lower bowel with either normal saline or 
sterile water, by means of a long single or return-flow tube, has given 
most excellent results. In instances of collapse, with the small compres- 
sible pulse, the introduction into the blood of a normal saline solution is 
of the same value here as in collapse under other circumstances. As a 
diuretic the frequent (hourly) subcutaneous injection of ether has been 
highly praised by some. As a general stimulant, to assist in the elimi- 



552 



PATHOLOGY OF LABOR. 



u.v 




Fig. 346. 

L.U.S. 




EX. OS, 



V. 



Lower uterine segment at completion of first stage of labor. Os uteri completely dilated. 

(From Edgar.) 
v. Cuff of vagina, ex.so. Border of external os, scarcely perceptible, u.v. J. Utero- vaginal junction. 

L. u. s. Lower uterine segment. 

Fig. 347. 




Bimanual dilatation of the parturient os. (From Edgar.) 

Os is fully dilated and is being stretched and paralyzed, to prevent subsequent accidents to the 

after-coming head during the extraction of the foetus. Compare Fig. 341. 



ECLAMPSIA. 



553 



nation from the lungs and to prolong life in the post-eclamptic stupor or 
coma, the free administration of oxygen is of the greatest value. Fur- 
ther, alcohol will often be needed as a stimulant during and after an 
eclamptic attack, and strychnine in the post-partum state and in the face 
of threatened collapse — although for physiological reasons it would seem 
to be contraindicated — has served us well. 



Fig. 348. 



* 




-:. : ^r,:,j^--mW :X '' 




Instrumental dilatation of the parturient os, preparatory to further manual dilatation, gauze packing, 
and the introduction of bougies or cervical dilators for the induction of labor. (From Edgar.) 

Finally, although no one has been or is a firmer believer than the 
writer in the efficacy of a prompt removal of foetal metabolism and of 
irritation for not only the control but the cure of the eclamptic condition, 
still he begs to enter a protest, first, against the careless use of the term 



554 



PATHOLOGY OF LA BOB. 



accouchement force as applied to the rapid, scientific, and intelligent 
emptying of the uterus; and, secondly, to the easy confidence with which 
this accouchement force has been recommended as the best, if not the only, 
means at our command for the control of eclamptic seizures, without 
attaching sufficient importance to the condition of the cervical barrier. 
By accouchement forcS are understood to day three operations, namely, 
(1) the complete instrumental or manual dilatation of the cervical canal, 
followed by (2) either combined or direct version, or the application of 
the forceps, and (3) the immediate extraction of the child. 



Fig. 349. 




Digital dilatation of the parturient os. (From Edgar.) 
Os admits one finger. Vaginal and supravaginal portions of the cervix present. Compare Fig. 341. 

The accouchement force of the older writers upon obstetrics was often 
quite another and more serious operation, for the condition of the 
cervical canal was frequently lost sight of, and it too often meant (1) 
the plunging of the hand or the application of the forceps through a 
cervical canal imperfectly dilated, and (2) the immediate extraction of 
the fcetus through this constricted os. That the latter definition of the 



ECLAMPSIA. 



555 



term still obtains seems proven by the frequency of accidents in the 
extraction of the foetus that are constantly being brought to light. 

Our maternity hospitals are repeatedly in receipt of ambulance or 
emergency cases due to the neglect on the part of the operator to fulfil 
the first condition of the operation, namely, complete dilatation. It is 
no uncommon event for emergency cases to be brought to our hospitals 



Fig. 350. 







Bimanual dilatation of the parturient os. (From Edgar.) 
Os admits two fingers. Vaginal and supravaginal portions of the cervix present, 
shortening of the cervical canal. Compare Fig. 341. 



Commencing 



with a podalic version or extraction partially completed because of the 
operation being attempted in the presence of a partially dilated os (Figs. 
344, 345) ; moreover, for uterine rupture to occur, due to the same cause. 
In Fig. 345 is represented the outcome of a premature extraction 
through an imperfectly dilated os. With such a complication — a rigid, 



556 



PATHOLOGY OF LABOR. 



imperfectly dilated external os, grasping the foetus tightly under the 
armpits — the loosening of the arms, the dragging of these, and subse- 
quently the head through the os will take considerable time, and not only 
forfeit the child's life but subject the lower uterine segment to dangerous, 
if not fatal, rupture. Our plea in these cases is not alone for complete 
dilatation or disappearance of the external ring, as seen in Fig. 346, but 
further, for a paralysis of the ring, as we see it performed in Fig. 347, 



Fig. 351. 




^ 



Bimanual dilatation of the parturient os. (From Edgar.) 
Os admits three fingers. Supravaginal portion of the cervix disappearing. 

so that the dangers of the extraction, whether by forceps or version, may 
be reduced to a minimum for both mother and child. 

The limits of the present article forbid entering upon the arguments 
for or against any particular variety of rapid manual or instrumental 
dilatation of the parturient os, further than to state that the writer's pref- 



ECLAMPSIA. 



557 



erence is for a rapid bimanual method, as shown in the illustrations, since 
he has given this method an abundant trial over a period of several years, 
and it has proved most satisfactory. 

The bimanual method is to be preferred to other digital and instru- 
mental methods, because (1) the membranes are preserved throughout the 
operation or until full dilatation is obtained; (2) there is no interference 
with the original presentation and position; (3) the sense of touch of the 
operator's fingers is unimpaired; (4) there is no constriction of the opera- 
tor's hands; (5) the amount of force exerted upon the external ring can 
be better estimated, and hence there is less likelihood of lacerations 
occurring; (6) in placenta previa there is less preliminary separation of 
the placenta by this method than by any other; (7) by no other method 
with which we are acquainted can not only complete dilatation, but also 



Fig 352. 




Bimanual dilatation of the parturient os. (From Edgar.) 
Os one-half dilated. Lateral position of the hands. 



complete paralysis of the parturient os, be so quickly and safely obtained 
(Figs. 344, 347). 

Again, the writer begs leave to protest against the undertaking of a 
rapid manual dilatation of the os (namely, the entire dilatation completed 
within an hour) before the cervix has become, at least slightly, relaxed 
by uterine action, and is already somewhat yielding. A rigid cervix, in 
the condition seen in Fig. 341, should receive preliminary treatment, by 
means of a cervical dilator of gauze or a hydrostatic bag, that will set 
up some uterine action and render the rings of the os yielding enough 
to make rapid dilatation a safe operation. In the presence of even a 
minimum amount of uterine action, or with a softening, yielding, and 
relaxing os, although the anatomical conditions shown by Fig. 341 



558 



PATHOLOGY OF LABOR. 



may obtain, one may still undertake rapid manual dilatation and pro- 
duce complete paralysis of the cervix within an hour, as seen in Fig. 
347. Far better a purely expectant treatment, as regards emptying the 
uterus, than the attempt rapidly to overcome a rigid os by manual meth- 
ods, the supravaginal portion of the cervix being present. The writer 
has known complete uterine rupture to result from such an undertaking, 
the maternal intestines prolapsing between the fingers of the operator. 
Fortunately for the eclamptic woman, the frequency of the attack 
increases proportionately with the progress of gestation, and, it may be 
added, with the increase of foetal metabolsim. Hence, the attack is more 



Fig. 353. 




Bimanual dilatation of the parturient os. (From Edgar.) 
Os two-thirds dilated. Entire effacement of the internal os. Compare Fig. 343. 

frequent in the latter part of pregnancy and in labor, when we can more 
readily and safely apply our surgical principle of treatment, namely, an 
early and rapid evacuation of the uterus. 

Unfortunately, the attack is four times more frequent in primiparse 
than in multipara?, and in the former the presence of the supravaginal 
portion of the cervix late in pregnancy, and of an unyielding and unre- 
laxed os, compels us to make use of preliminary and temporizing means 
before we can safely perform a rapid dilatation of the os and subsequent 
extraction of the foetus. It is in such cases, and at such a critical time, 



ECLAMPSIA. 



559 



when one is waiting for the measures preparatory to a rapid dilatation 
and emptying of the uterus to act, and to give us at least a yielding and 
relaxed cervical canal, if not a partial disappearance of the internal os, 
that the writer has found veratrum viride most valuable and life-saving, 
by reason of the various actions of the drug already mentioned. 

' In order to render the preferred method of rapid dilatation of the 
pregnant or parturient os more graphic, and also that the sequence of the 






Fig. 354. 



% 




Bimanual dilatation of the parturient os. (From Edgar.) 
Os is fully dilated and is being stretched and paralyzed to prevent subsequent accidents to the after- 
coming head during the extraction of the foetus. Compare Fig. 346. 

different steps of the operation may more clearly be set forth than they 
are in the limited number of illustrations in the article upon puerperal 
eclampsia, the nine illustrations 1 (Figs. 348 to 356) are introduced. 

The illustrations demonstrate the different steps in a rapid dilatation 
of the os uteri, commencing with instrumental dilatation (Fig. 348), at 



1 These illustrations are from photographs of composition and plaster models, and have already 
appeared in a series of articles on " Methods and Aids in Obstetric Teaching," published in the New 
York Medical Journal, November 14, 21, 28, and December 5, 1896. 



560 



PATHOLOGY' OF LABOR. 

Fig. 355. 




Bimanual dilatation of the parturient os. (From Edgar.) 
Internal view, showing the position of the fingers. Os admits three fingers readily. Internal os 
still present. No encroachment of the fingers upon the cavity of the lower uterine segment. Com- 
pare Fig. 356. 

Fig. 356. 




Bimanual dilatation of the parturient os. (From Edgar.) 
External view, after a photograph of the operation as performed at the Emergency Hospital, 

New York. 



ECLAMPSIA. 561 

a time when the internal os has partially disappeared, and the cervical 
canal is somewhat relaxed and yielding, continuing with digital dilata- 
tion, and finally ending with bimanual stretching and paralyzing of the 
fully dilated parturient os uteri (Fig. 354). In Fig. 355 is shown the 
position of the fingers in the bimanual method of cervical dilatation, as 
seen from the uterine cavity; and Fig. 356 is added, which is after an 
actual photograph of the operation of manual dilatation of the par- 
turient os, taken from nature at the Emergency Hospital (Bellevue Hos- 
pital service), in order that the position of the patient and the position 
of the operator's hands during the operation may be clearly seen. 

36 



CHAPTER XXIV. 

DIABETES.— CARDIAC DISEASE. 

Diabetes mellitus is a dangerous complication of labor and the puer- 
peral state, as it is well known to be of surgical operations. Fortu- 
nately, it is rarely met with in obstetric practice. The disease may ante- 
date the pregnancy or may develop in the course of it. That it may 
occur as a result of pregnancy would seem possible from the fact that in 
exceptional instances the disorder appears only during gestation, subsid- 
ing after delivery. It may be present in one or more and absent in 
subsequent pregnancies. A transient glycosuria is met with in a small 
percentage of pregnant women, but is most frequently a lactosuria. 
Lanz administered chemically pure grape-sugar to several women imme- 
diately after labor in quantities of 100 grammes to each. The urine 
was drawn by catheter just before the ingestion of the sugar and at the 
end of two, four, and six hours subsequently. In 30 per cent, of the 
urines grape-sugar was found. These observations go to prove that 
sugar metabolism is diminished in the first few hours or days of the 
puerperium and probably in the later weeks of pregnancy. 

Frequency. There are no sufficient data on which to base a definite 
statement of the frequency of diabetes as a complication of labor. 
Statistics show, however, that the disease is associated with pregnancy 
in less than 1 per cent, of diabetic women. Women suffering from 
diabetes are usually sterile. 

Diagnosis. The essential phenomena of the disease are the same in 
pregnancy as in other patients. The diagnostic evidence is to be sought 
chiefly in the urine. The test for sugar should be included in the usual 
urinary examinations during pregnancy, yet lactosuria must not be mis- 
taken as evidence of diabetes. Lactose is sometimes present in the 
urine during the later weeks of gestation in healthy women. The liquor 
amnii is usually excessive in amount, and it contains sugar and some- 
times acetone. 

Prognosis. Pregnancy iu women previously diabetic terminates in 
abortion in about 33 per cent, of cases. The prognosis for the mother 
is especially grave when the disease is aggravated by pregnancy and 
resists treatment. The danger to life is greatest in the later months. 
Fifty per cent, of the mothers suffering from this disease die soon after 
labor. Of 22 cases collected by Matthews Duncan, 4 were fatal after 
delivery, within the puerperal period, death being due to collapse and 
coma. The mortality for the children born of diabetic women exceeds 
40 per cent. It very frequently happens that the foetus dies soon after 
becoming viable. Sometimes the child is dropsical. In one case the 
child had glycosuria. In view of these facts a woman the subject of 
diabetes ought not to become pregnant. 

Treatment. The medicinal and dietetic treatment of diabetes in the 

( 562 ) 



CARDIAC DISEASE. 563 

pregnant patient does not differ from that usually adopted under other 
circumstances. If the symptoms are pronounced, and especially if they 
are not relieved by treatment, the pregnancy should be terminated. 

Cardiac Disease. 

The physiological hypertrophy of the heart in pregnant women testifies 
to the increased work put upon it during gestation. Pre-existing cardiac 
lesions are liable to be aggravated by pregnancy, and in advanced disease 
the heart may seriously be crippled in the later months. The circulatory 
disturbance usually begins near midpregnancy. The danger is especially 
great under the added strain of labor, and it culminates in the third 
stage, when a large volume of blood is abruptly thrown upon the venous 
side by the uterine retraction, causing dilatation of the right heart. Yet 
in a considerable proportion of cases the heart, even though damaged, 
proves equal to the increased demand upon it, and apparently sustains 
little or no added injury. 

The mitral valve, either alone or with others, is oftenest affected. Of 
92 cases of valvular disease in pregnancy collected by Porak, the mitral 
valve alone was diseased in 57; both mitral and aortic valves were 
involved in 22. In 22 there was mitral insufficiency, in 13 mitral 
stenosis, and in 22 both conditions were present; in 13 the aortic valve 
only was diseased, insufficiency existing in 9, stenosis in 2, and the 
double lesion being present in 2. 

Prognosis. Most fatal of the valvular lesions in pregnancy is mitral 
stenosis. Eight of the thirteen cases recorded by Porak terminated fatally. 
McDonald reports fourteen cases with nine deaths. In double mitral 
lesions the mortality is still greater. The death-rate in aortic disease is 
from 23 to 25 per cent., while in mitral insufficiency, the best borne of 
all the valvular affections, the proportion of deaths is not far from 13 
per cent. 

The period of greatest danger is the close of the second stage of labor. 
During the pains of this stage the venous circulation is impeded by the 
prolonged and violent expulsive efforts. The right heart is dilated, as 
indicated by the swollen veins of the neck and the cyanotic hue of the 
face. At the moment of expulsion or directly after, as the uterine sinuses 
are emptied, an additional volume of blood is thrown upon the already 
overloaded right heart, often with fatal effect. Obviously the prognosis 
must depend largely on the condition of the myocardium. With full 
compensation the patient may pass safely through pregnancy and labor. 
In advanced cardiac disease the prognosis is always bad. In marked 
failure of compensation, with dilatation of the right heart and much 
pulmonary congestion or oedema and albuminuria, it is extremely grave. 
Owing to the increased labor imposed upon the heart in the later months 
of pregnancy, existing cardiac disease is, as a rule, permanently aggra- 
vated by child-bearing. 

All forms of heart disease predispose to abortion. In a large propor- 
tion of cases the pregnancy terminates prematurely. The immediate 
cause of the abortion may be excess of carbon dioxide in the blood or 
placental apoplexies. 

The tendency to post-partum hemorrhage is increased by the circula- 



564 PATHOLOGY OF LABOR. 

tory obstruction, yet moderate bleeding at the close of labor is conserva- 
tive by relieving the venous engorgement. 

Symptoms. The symptoms of valvular disease vary according to the 
extent of the lesion, the valves affected, and the amount of compensatory 
hypertrophy which is present. They do not differ essentially from the 
usual manifestations of similar lesions under other circumstances. Pal- 
pitation, dyspnoea, and more or less precordial distress are common in 
the later months of pregnancy, even in the milder forms of valvular 
disease. 

Dilatation of the right heart is attended with visible pulsation of the 
veins of the neck and with epigastric pulsation. The first sound is weak 
and the area of dulness is increased. Pulmonary congestion or oedema 
and venous stasis in other viscera frequently develop, especially during 
labor. 

Treatment. Peter says a woman with heart disease should not marry; 
if she is married she should not become pregnant; if she has passed 
through one or two pregnancies safely she should not again become 
pregnant; and, finally, if she gives birth to a child, she should not be 
allowed to nurse it. Peter's dictum, however, is too sweeping. It 
should be limited rather to the grave forms of valvular defect and to 
incompetence of the heart-muscle. 

The hygienic management of cardiac disease in pregnancy is impor- 
tant, and consists in the avoidance of undue exertion, physical or mental, 
of sudden chilling of the surface of the body, and in the removal, if 
possible, of all sources of nervous disturbance. 

The medicinal treatment either during pregnancy or labor is for the 
most part symptomatic. Iron, arsenic, or strychnine are frequently use- 
ful as tonic measures. For cardiac supports strophanthus in 5-minim 
doses of the tincture several times daily, or the tincture of digitalis, 5 to 
10 minims three times daily, may be used, or digitaline may be given in 
To o" t° eV g ram doses. Trinitrine, by preventing the contraction of the 
arterioles caused by digitalis, is a valuable auxiliary to the latter drug. 

The obstetric management of serious cardiac disease will often tax the 
physician's skill and judgment. When the woman is in imminent peril 
the artificial interruption of pregnancy is demanded. Yet, when the con- 
ditions are bad enough to justify interference, even a premature labor is 
attended with great danger. Kaltenback regards uncompensated valvular 
disease as a positive indication for the induction of labor. Fehling 
would terminate the pregnancy when, in addition to the non-compensa- 
tion, there is chronic bronchitis with marked emphysema. In the pres- 
ence of such pulmonary congestion and oedema, with extensive visceral 
complications, general anasarca or ascites, and extreme dyspnoea, and 
especially if the symptoms become more pronounced notwithstanding 
treatment, the uterus should be emptied. Winckel, on the other hand, 
speaks discouragingly of the results of premature delivery. 

The indications after labor has begun are to deliver the patient with 
as little exertion on her part as possible. Chlororoform should be used 
to diminish violent effort and to limit shock. After sufficient relaxation 
forceps should be employed. Should the dilatation be slow, it may be 
hastened by artificial means; manual dilatation, or, if the emergency 
requires, Durhssen's incisions should be practised. Meantime, the heart 



CARDIAC DISEASE. 565 

should be braced with one or more of the usual cardiac supports — stro- 
phantus, sparteiu, digitalis, trinitrine, and caffeine. These agents act most 
promptly and efficiently if given by the hypodermic method. Sudden 
asystole at the end of the second stage is best met with inhalation of 
nitrite of amyl and with hypodermics of ether or strychnine. When 
these measures fail, from 10 to 16 ounces of blood should be taken from 
the arm. Ergot should be proscribed, since it contracts the arterioles 
and increases the circulatory obstruction; moreover, it limits the blood 
loss from the uterus. Moderate bleeding after delivery is beneficial. 
When not sufficiently free it should be favored by the use of douches of 
warm sterile water, at a temperature not exceeding 40° C. (105° F.). 
If during the labor the patient suddenly expires, the child being viable, 
accouchement force, or, if need be, Cesarean section, should at once be 
performed, in the hope of saving the child. 



PART VII. 

PATHOLOGY OF THE PUERPERIUM 



CHAPTER XXV. 

ANOMALIES AND DISEASES OF THE BEEASTS AND NIPPLES. 

Normal Data. The reader will recall that each mamma empties its 
secretion through the nipple by means of about twenty ducts in direct 
communication with the mammary acini. These ducts are lined with 
cuboidal epithelium. 

The acini are composed of saccular dilatations of the terminal ends of 
the smallest ducts, and possess a membrana propria lined with character- 
istic secretory epithelium. White, fibrous and adipose tissues surround 
the acini in varying proportions, according to age and the individual. 
Like all other active glands, the mammae are rich in bloodvessels, lym- 
phatics, and nerves. 

The blood-supply is peculiar in that the ducts are surrounded by a 
vascular plexus, instead of parallel vessels inosculating with one another 
as in the voluntary muscles. 

The nerve-endings have never been conclusively traced; but they 
doubtless terminate in the parenchymatous elements. 

The lymphatics communicate ultimately with a single large channel 
extending to the axilla. 

The breasts reach fullest development during pregnancy, when the 
glandular epithelia become enlarged and filled with milk globules. 

Anomalies. 

Supernumerary nipples and breasts, defective development of the 
nipples, and absence of one or both breasts are met occasionally. 
Complete absence of the gland is rare, but imperfect development is 
common. There are but few cases reported of hypertrophy of the 
breast. It is said that lactation has been known to reduce an abnor- 
mally enlarged breast. Polymastia (supernumerary breasts or nipples) 
is common. The location varies, but is usually below the true breast. 
There may be one or more supernumerary breasts or nipples, which 
have been recorded as being situated either in the shoulders, umbilicus, 
back, groin, labium, or buttock. One case was reported as having nine 
breasts ; another, ten nipples. These anomalies are of obstetric interest 
only in so far as they may affect the woman's ability to nurse her child. 

Defects of the nipples are especially important, as they may interfere 
with nursing. Both congenital and acquired deformities are common. 

(567) 



568 PATHOLOGY OF THE PUERPERIUM. 

The nipples may be primarily small, sunken, or inverted, or imper- 
fectly developed from pressure of faulty clothing. 

The nipple lesions of lactation are largely the result of defective devel- 
opment, and consequent difficulty in nursing. 

Sore Nipples. 

Nipple lesions of greater or less severity occur in nearly 50 per cent, 
of nursing women, and begin usually within the first few days after 
suckling is inaugurated, being due to maceration and abrasion of the 
cuticle by the infant. They are of clinical importance by virtue not 
only of the exquisite suffering they may occasion during nursing, but 
especially of their etiological relation to mastitis. Mere erosions may 
soon heal and give rise to no further trouble. While they persist they 
are often extremely painful, and they commonly lead to more serious 
lesions. 

Fissures occur at the base or top of the nipple. The latter run trans- 
versely to the axis of the breast. Ulcers not infrequently result, and 
when milk-ducts open into the base of an ulcer they are occluded as the 
ulcer heals. 

Etiology. Defective development and deformities, by rendering nurs- 
ing difficult, frequently act to increase the injuries inflicted on the nipples 
during suckling. Needless maceration of the nipples by too prolonged 
and frequent nursing is often the cause of erosion and fissure. Soor or 
aphthae (thrush, sprue) in the child's mouth exposes the nipples to in- 
fection. Uncleanliness of the nipples in the later weeks of pregnancy, 
and especially during lactation, is a common source of septic invasion. 

Treatment. Prophylactic. Prevention should begin in the man- 
agement of pregnancy. The presence of defective nipples should not 
escape the antepartal examinations. Teach the woman to draw them 
out daily during the last two or three months of pregnancy with clean 
fingers or by means of a suitable breast-pump. This practice not only 
tends to develop the nipples, but also prepares them to withstand better 
the mechanical violence of beginning nursing. The mother should be 
warned of the injury that may be done by tight clothing. 

For at least a month before labor special attention must be paid to the 
cleanliness of the parts. Daily bathing in warm water and a bland soap, 
or with a solution of borax — a tablespoonful to the pint of boiled water 
— is a valuable precaution. The use of agents for hardening the nipples 
is not advised. There is reason to doubt that bathing the nipples with 
alcoholic and other astringent solutions is a suitable preparation for nurs- 
ing. It is more than probable that hardening the skin predisposes it to 
crackingo It would seem more rational to keep the nipples as supple as 
possible. The application of fresh cacao butter or some equally bland 
emollient, as lanolin, after the daily cleansing promotes this end. 

Dr. J. M. Mabbott praises the following treatment : Daily for a month 
or more before labor the patient anoints the nipples at night with lanolin, 
working it thoroughly into them by kneading them between the thumb 
and fingers. In the morning the nipples receive a prolonged scrubbing 
with a soft nail-brush and pure soap and water, care being taken not to 
abrade the skin surfaces. The nipples are then rinsed and dried. 

When nursing begins the delicate cuticle of the mammilla may be broken 



ANOMALIES AND DISEASES OF THE BREASTS AND NIPPLES. 569 

and abraded, and during the post-partal month the septic exposure is 
especially increased by the contact of hands liable to be infected from 
the lochial discharges. The occurrence of thrush or of ophthalmia in 
the child obviously adds to the risk of infection. Hence the need of 
a cleanly management of the nipples during the first weeks of lactation. 
The avoidance of septic contact is clearly important. Bathing with a 
boric-acid lotion before and after each nursing is specially advised. A 
saturated aqueous solution is not too strong. Cleansing the infant's 
mouth with a similar wash before and after each nursing is in the 
interest of both mother and child. Care must be taken not to abrade 
the buccal mucous membrane, lest the practice invite the trouble which 
it aims to prevent. 1 More active antiseptics are more effectual, but they 
require greater care in use. The writer has employed with satisfaction a 
nipple dressing wet with a mercuric iodide or chloride solution, 1-10,000 
or 1-5000 ; the mercurial must be rinsed off with boiled water or 
with the boric-acid solution before nursing. 

To limit the injury done by maceration and bruising, a single nursing 
need not occupy more than ten or, at the most, twenty minutes, and 
regularity should be insisted upon. See that both breasts are nursed, 
each on an average from seven to ten minutes. 

The cacao-butter or some other similar inunction may be employed 
with advantage after each nursing, the surfaces having first been cleansed 
as already detailed. 

Curative Treatment. Excoriations and slight fissures heal in most 
cases under proper and timely antiseptic treatment. An ointment of 
equal parts of subnitrate of bismuth and castor oil may be used as ad- 
vised by Hirst. The writer has generally preferred to this a similar 
ointment made with the glycerite of starch. But the glycerin preparation 
may not always be well borne by the skin. The ointment should fre- 
quently be sterilized by heat. Before applying, the parts are disinfected. 
A valuable agent for the latter purpose is the hydrogen dioxide. While 
a host of nipple lotions and other applications have been recommended 
in these affections, none is more rational or promises better results in 
ordinary cases than some simple but carefully executed antiseptic plan of 
treatment. 

Pain during nursing may be relieved to some extent by pencilling the 
nipple five or ten minutes before the child is put to the breast with a 1 
to 5 per cent, cocaine solution. The solution ought to be heated to the 
sterilizing point shortly before using. 

A 1 or 2 per cent, carbolic lotion applied in the same manner is some- 
times useful as an anaesthetic. The addition of one-tenth its volume of 
glycerin prolongs the action of the lotion and keeps the skin soft. 

After the application of drugs the nipples should always be cleansed 
before nursing. 

In excoriations and fissures that are not too sensitive and do not bleed 
readily, nursing through a nipple-shield may be tried. The shield pro- 
tects the nipple from the friction, and to some extent from the maceration 
of suckling. Unfortunately for this method, the child may not accept 

1 An easy and reliable method is to wrap a small piece of absorbent cotton or soft 
cheesecloth around one of the fingers, and, after saturating it with the boric-acid wash, to 
rinse out the child's mouth carefully. This allows all surfaces of the mouth to be bathed. 



570 PATHOLOGY OF THE PUERPEBIUM. 

the substitute for the natural nipple. If artificial nipples are used, it is 
important that they be rendered aseptic by boiling for five minutes in 
water immediately before using and not handled with unclean fingers. 

Similar protection to the nipple lesions is afforded, though in a less 
degree, by coating the affected surfaces with a pellicle of compound 
tincture of benzoin. 

Deep and painful fissures may be treated with the solid stick of nitrate 
of silver. The entire raw surface should be touched. The lips of the 
fissure being well separated, the caustic point is drawn slowly through 
it. This is repeated, if required, in three or four days. Care must be 
taken that no excess of moisture is present, otherwise the dissolved silver 
salt may trickle over the surrounding surfaces and healthy structures 
be injured. A serious objection to this treatment is the exquisite pain 
it causes. This may in great measure be prevented by first benumbing 
the part with a 4 per cent, cocaine solution. After the application of 
the caustic the nipple may be covered with a piece of lint well wet with 
the anaesthetic lotion. 

Instead of the solid stick, two or three applications daily of an aqueous 
solution of the nitrate of silver may be preferred. In the strength of 1 
or 2 per cent, it causes little pain and frequently does good service. The 
affected nipple should be rested, if possible, for twenty-four hours or 
more. 

When other measures fail, suspension of nursing for one or two days 
sometimes succeeds. If both breasts are affected each may be rested on 
alternate days. 

It is very rarely that the nipple lesions are so rebellious to well-directed 
treatment as to necessitate the total abandonment of nursing. 

Mastitis. 

Mastitis occurs in 5 to 6 per cent, of nursing women, oftenest in prini- 
ipar?e, and may or may not terminate in suppuration. In the great 
majority of cases it begins within the post-partum month. 

Etiology. That the essential factor in mastitis is sepsis does not 
admit of discussion. Here, as elsewhere, the suppuration and the 
local morbid process which leads up to it are due to infection. Obvi- 
ously the offending organism may be any of the pus-producing germs. 
Most frequently found, according to Escherich, are the staphylococcus 
aureus and albus. The streptococcus of pus is next in order of frequency. 
The lochia is a prolific source of infectious material, which during child- 
bed is added to the usual septic exposures. 

The predisposing causes and the methods of infection are questions 
involved in some dispute. Impaired general health and local mechan- 
ical injuries, diminishing the resisting power, are obviously important 
predisposing factors in many cases. Contusions of the breast from blows 
or from bruising with the breast-pump may become the starting-point of 
mastitis. 

The influence of milk stasis, which is so large a factor in the popular 
belief, is differently estimated by obstetric writers. Olshausen denies that 
it causes inflammation. Roser holds that milk retention is a result, not 
a cause, some of the lactiferous ducts being occluded by inflammatory 



ANOMALIES AND DISEASES OF THE BREASTS AND NIPPLES. 571 

swelling of surrounding structures. Others think milk stasis may favor 
the growth of bacterial organisms. Possibly retention by damaging 
the delicate endothelium of the lacteal ducts in the engorged areas may 
become a factor in the septic invasion. Engorgement alone is not a 
competent cause. 

That the nipple lesions so common during early lactation hold a 
prominent place among the predisposing causes of infection does not 
admit of doubt. Fissures of the nipple and even the abrasions, which 
are almost invariably produced by the friction of the child's tongue and 
lips in the first weeks of lactation, expose the lymphatics directly to the 
entrance of septic organisms. 

That the morbific agent in a considerable proportion of cases enters 
by the lactiferous tubules is beyond question. It is well known that 
pathogenic germs may penetrate healthy mucous or serous surfaces. Fre- 
quently the way is made easy by the injury done by milk engorgement 
or by mechanical violence. That pyogenic bacteria which have gained 
access to the milk ducts from without may pass into the deep structures 
of the gland, even against the milk stream, cannot be doubted. Recent 
observations have shown that staphylococci are frequently present in the 
milk of perfectly normal breasts. Palleski examined the milk of twenty- 
two healthy nursing women and found staphylococcus albus in ten. Sim- 
ilar observations have been made by other investigators. Honigman 
and Ringel contend that human milk normally contains the staphylo- 
coccus pyogenes albus and aureus. That mastitis occurs so infrequently, 
despite the frequent presence of the microbic causes of suppuration, must 
be explained by the fact that a favorable condition of the soil as well as 
the presence of the germ is necessary to bacterial growth. 

A possible source of mammary inflammation which is not often men- 
tioned by obstetric writers is infection through the blood channels. 
Karlinski declares that micro-organisms from the cavity of the uterus in 
process of involution may be found in the blood. Escherich affirms that 
staphylococci which have gained access to the blood through infection of 
the genital apparatus are excreted in the milk as well as by other chan- 
nels. In the milk of infected puerperre he found, without exception, 
staphylococcus aureus or albus. That infection of injured mammary 
tissues is possible from sepsis in remote organs is abundantly established 
by clinical observations and by the experiments of numerous observers 
on the localization of septic processes. Not alone direct injuries of 
the breast invite such localization, but there is reason to believe that 
general pathological conditions, even exposure to cold, may act in this 
manner. 

We must conclude that the infecting organisms may reach the gland 
structures through the lacteal ducts, the lymphatics, or the bloodvessels; 
that nipple lesions, milk stasis, contusions of the breast, impaired general 
health, probably chilling, and genital or other remote infections are among 
the predisposing causes. 

Symptoms. The essential symptoms of mastitis are pain, swelling, and 
localized tenderness in the breast, together with more or less rise of tem- 
perature. The attack is frequently ushered in by a chill or slight chilli- 
ness. 

When pus forms fluctuation may usually be detected, and a deep red 



572 PATHOLOGY OF THE PUERPERIUM. 

or bluish discoloration of the skin is observed at the place where the pus 
comes nearest the surface. Yet fluctuation may be absent in deep-seated 
suppuration, and the evidence usually afforded by the appearance of the 
skin may be wanting, at least for a time, after pus is present. 

Forms. There are three principal forms of mastitis : Glandular, sub- 
glandular, subcutaneous. To the latter two the term perimastitis would 
perhaps more properly apply. The differential diagnosis of these varie- 
ties of mastitis depends upon the source of the infection and the location 
of septic foci, together with the degree of systemic disturbance. 

In the subcutaneous form the lesion is usually single and differs little 
from superficial phlegmon in other parts of the body. In the glandular 
form more pain and more constitutional disturbance are present than in 
the subcutaneous variety; prodromal chill is usual; the lesion is often 
multiple; the gland is indurated. In the subglandular form the pain is 
deep seated and more intense, temperature persistent and high, the gland 
not indurated, and, when suppuration has occurred, it floats upon the 
surface of the fluid. Pus is detected by passing an aspirating needle 
behind the gland. Suppuration may eventuate in any of the forms, de- 
pending upon the patient's lack of power to resist the infection and upon 
the quantity, nature, and virility of the invading parasites. It must not 
be forgotten that two or all forms may coexist. 

Treatment. Prophylactic and Abortive. Milk engorgement is 
combated by training the child early to nurse. Congestion or engorge- 
ment occurs, usually on the second or third day. A slight fever and 
some distress referred to the breast are usually the first symptoms. The 
infant should receive its first lesson as soon after birth as the condition 
of the mother will permit, usually within six or eight hours, and no 
effort should be spared in teaching the child to suckle before the milk 
secretion is fully established. The use of the breast-pump, as a 
rule, is unsatisfactory. It frequently fails, and is liable to bruise the 
breast. 

At the hands of a skilful nurse, massage is often useful for the relief 
of overdistention, either of the entire breast or of single lobules. It is 
contraindicated in the presence of inflammation, and is permissible only 
when not painful. The breasts should be well oiled in order that the 
nurse's efforts be not expended in mere friction, but be rather a deep 
kneading directed to the gland. The stroking is practised in the direc- 
tion of the lactiferous ducts, from the base of the gland toward the 
apex. 

In hypersecretion the compression-binder is an extremely valuable 
measure. A well-made Murphy binder is especially recommended. It 
is applied firmly, the pressure being evenly distributed over the breast 
by a moderately thick layer of cotton-wool under the binder. An open- 
ing in the centre of the cotton compress prevents injurious pressure 
upon the nipple. Compression is useful both as a preventive and an 
abortive measure in mastitis. 

Topical applications of oleate of atropia are effectual for diminishing 
the milk secretion, but they must be used with care lest the secretion be 
too much repressed or the patient present an idiosyncrasy to belladonna 
even in small physiological doses. Saline catharsis and the restriction 
of liquids are especially indicated in over-free secretion. 



ANOMALIES AND DISEASES OF THE BREASTS AND NIPPLES. 573 

Essential for the prevention of mastitis is the preventive and curative 
treatment of nipple lesions. As has already been said with reference 
to the prophylactic care of the mammillae during the early weeks of 
lactation, it must be remembered that prolonged maceration of the nip- 
ple in the child's mouth is injurious. A single nursing need not occupy 
more than ten or, at the most, twenty minutes, and regularity should 
be insisted upon. 

A part of the prophylaxis which must not be overlooked is addressed 
to the general health of the patient. Tonics are indicated in the majority 
of convalescents from childbirth. 

Applications of unguent urn Crede may be of service. About a drachm 
should be rubbed well into the breast night and morning. 

Treatment of Suppuration. When pus forms in either variety 
of mastitis it should immediately be evacuated. An anaesthetic is re- 
quired except in simple subcutaneous abscess. Ethyl chloride (Kelene) 
may be used to freeze the tissues over the area to be incised when the 
abscess is not too extensive, and when the type is either subcutaneous 
or glandular. The incision should radiate from the nipple, to avoid 
severing the milk-ducts, and should be large enough to admit the linger 
freely. When but one incision is made, it is to be located at the most 
dependent point of the abscess-cavity. It is well to avoid the areola, 
unless the incision can be kept wholly within that area. Otherwise an 
unsightly scar results, owing to pigmentation of the cicatrix. 

The finger is then introduced and the cavity thoroughly explored. 
If the abscess be large, and especially if several loculi are found, counter- 
openings should be made at remote points. The cavity or cavities are 
then thoroughly irrigated with the normal salt solution or with peroxide 
of hydrogen. A drain of washed-out strip iodoform gauze is placed in 
each opening, and a large compress of aseptic cotton or cheesecloth is 
applied and held firmly by a breast-binder. The dressings must be 
changed daily for six to eight days and the irrigation, as a rule, repeated. 
By the end of that time the incisions may generally be allowed to close 
unless pus is present. One or two soft flexible rubber drainage-tubes 
for each opening may be substituted for the gauze, if preferred, after the 
first few days. The tubes should be shortened from day to day as the 
abscess cavity diminishes. 

One of the most valuable agents in aborting mastitis is the early and 
continued application of cold, either by the ice-coil or, preferablv, bv the 
ice-bag. The bag should not be placed directly on the breast, but 
should have two or three layers of flannel between it and the surface of 
the breast. Continued cold applied in this manner is almost a specific 
for pain, and tends also to abort suppuration. It is possible that the 
cold may limit the rapid development of the micro-organisms, or at 
least check their growth from the thermal conditions present. 

Tonics, milk punches, and especial attention to the regularity of the 
bowels are indicated. 

Agalactia. 

The causes of agalactia, or diminution of milk secretion to a decree 
below the normal, are general and special. Adynamia of any origin may 



574 PATHOLOGY OF THE PUERPERIUM. 

be accompanied with insufficient milk secretion. This may be due to 
diarrhoea, fevers, hemorrhages, serious organic lesions, insufficient nour- 
ishment, or mastitis. On the other hand, congenital or acquired mal- 
formations may be the cause. Lack of development of the glandular 
tissue is one of the most frequent causes, in which heredity plays an 
important part. 

In the cases dependent upon general conditions every effort must be 
made during pregnancy to restore the patient's tone and vigor ; and 
after labor liberal quantities of fluid — milk preferably — must be taken. 
Malt, Russell emulsion, somatose (3 or 4 teaspoonfuls daily), and foods 
containing phosphorus are believed to be useful. Thyroid extract, gr. j 
3 to 5 times daily, is said to increase the quantity and to improve the 
quality of the milk. Massage of the abdomen from the pelvis to the 
breasts, including the latter, it is claimed increases the amount of blood 
brought to the mammary glands. The breasts may be stimulated by 
massage and by daily applications of faradism. 

Congenital conditions are not amenable to treatment; whereas, acquired 
malformations, such as stenosis of milk-ducts, or parenchymatous degen- 
erations due to indurative processes, can be modified in some cases by 
timely treatment. 

As inflammatory lesions are the common local causes of these mam- 
mary changes, it is of first importance to prevent their occurrence, and 
if not successful to limit them as much as possible. 

Galactorrhea. 

Galactorrhcea is an excessive secretion of milk which persists after wean- 
ing. The cause is unknown. The quantity of milk is very large and 
its quality thin and watery. One or both breasts may be affected, and 
the condition may seriously impair the general health. 

Treatment. Treatment consists in firm compression of the breasts 
with a breast-binder, the exhibition of iodide of potassium, gr. x t. i. d., 
and the persistent use of ergot for a considerable period. Oleate of 
atropia may be applied locally with caution. General tonics and hsema- 
tinics are especially indicated. 

Galactocele. 

Galactocele is a condition in which a mammary acinus becomes dis- 
tended with milk. This may be due to congenital conditions, such as 
absence of the duct, stenosis, or atresia; or may result from inflamma- 
tion. It is single or multiple, and may affect one or both breasts. 

Treatment. Treatment is indicated where the condition is pro- 
gressive, and consists either in laying the cyst open under aseptic pre- 
cautions, and treating it as an abscess-cavity, or dissecting it oat and 
closing the wound at once. 

It must not be forgotten that galactocele sometimes undergoes spon- 
taneous cure, the milk becoming inspissated and, finally, inclosed in a 
shrunken sac, and having the consistence of sebaceous matter. 



ANOMALIES AND DISEASES OF THE BREASTS AND NIPPLES. 575 



Polygalactia. 

This is an excessive secretion of milk during lactation, and is to be 
distinguished from galactorrhea, in which the milk secretion persists 
after weaning. It is often sufficient to affect the general health. 

Treatment. Restrict diet, especially liquids ; also regulate the 
patient's food. Apply compression binder, give salines, and, if neces- 
sary, evacuate the superabundant amount of milk by breast-pump. 
Massage is contraindicated except in " caking." 

Hyperlactation. 

This occurs when the child is nursed beyond the weaning age. A 
recent case was reported at one of the Brooklyn hospitals ; a negro boy 
three and a half years of age was sent by his mother to the hospital to 
be weaned. 

Oftentimes the health of the mother in such cases suffers markedly, 
so much so as to demand a change of climate. 

Actual treatment consists in weaning the child, prescribing tonics for 
the mother, and a compression-binder for a short period. The treat- 
ment advised in galactorrhea is indicated in these cases. 



CHAPTER XXVI. 

PUERPERAL INSANITY. 

The term Puerperal Insanity is applied to the psychoses of pregnancy, 
labor, or the puerperinra. It does not indicate in itself any single form 
or type of insanity, but refers only to the etiology. Usually the form 
of mental derangement is either a melancholia or a mania. 

As in so many other mental diseases, there must be a prepared soil,, 
which consists in an hereditary predisposition, and here the likeness 
to the so-called periodical and recurrent insanities is most pronounced. 
While primiparce are most likely to develop such mental derangement, 
there are many women who have repeated attacks of puerperal insanity 
as an accompaniment of subsequent accouchements, and doubtless its 
crisal development is oftentimes merely an exacerbation, the patient's 
mental state never being after the first attack an entirely normal one. 
The number of women who for the first time become insane after the 
second or third parturition is small in comparison with those whose dis- 
order attends the first confinement. 

Etiology. Undoubtedly there are a large number of factors both 
physical and mental that contribute to the production of insanity at this 
important epoch, and while certain variations take place in the symp- 
tomatology of the insanities coincident with the pregnant state or that 
following birth, the bodily and mental causes very often play a contin- 
uous part. Much stress has been laid upon the sense of shame and 
fear connected with the birth of an illegitimate child, and undoubtedly 
the worry and attendant suspense lead to such mental exhaustion and 
disorder as to end in the overthrow of the patient's ordinary mental 
condition. Strange to say, however, in the majority of cases there 
appears not only to be a gradual evolution of symptoms, except in a 
very small number of melancholic cases, but there are mania and confu- 
sion which are suggestive of a physical cause presently to be more fully 
referred to. It cannot be gainsaid that where conception has been the 
result of guilty intercourse, and where attempts have been made to pro- 
duce criminal abortion, there may be not only very great mental distress 
and apprehension, but an undermining of physical strength, which are 
sufficient in themselves in certain neurotic individuals to lead to insanity. 
In Scotland particularly the influence of illegitimacy is very great, 25 
per cent, of all cases occurring in the experience of one writer being 
those in which the offspring were illegitimate. This, according to Lewis, 
does not appear to be the case in England, where 61 of 6Q cases observed 
by him were married women. After all, the importance of this element 
depends very much upon the moral sensibility and religious training of 
the community. 

Among other psychical influences concerned in the creation of this form 
of insanity may be enumerated the development of the maternal instinct, 

(576) 



PUERPERAL INSANITY. 577 

the tortures of poverty, and the suffering that the woman may undergo 
as the result of neglect or cruelty of her husband. Among the physical 
causes may be mentioned certain conditions of exhaustion which are due 
to over-exertion during the months previous to delivery, the loss of blood 
at this time, or certain imperfectly understood forms of autotoxis. Albu- 
minuria, which in former years was supposed next to local septic infec- 
tion to play a part that would fully account for the puerperal psychosis, 
is not nowadays regarded as a sufficient explanation; in fact, the urine 
of the puerperal insane, as a rule, shows the absence of albumin, and 
there are many cases where the disease develops in women whose kidneys 
have from the first been unaffected. The dangers of septic infection from 
the uterine cavity itself have been equally exaggerated. Lusk, whose 
conservative opinions are well known, is disposed to take the view that 
septic infection is more likely to take place when bacteria are introduced 
from outside the body, and suggests that the toxaemia due to the agency 
of the bacterium coli is often at the bottom of wrongly ascribed toxis. 

The writer's recent investigations as to the origin of insanity which is 
due to the absolution of the products of intestinal putrefaction lead him to 
believe that the cause of many cases of puerperal derangement is to be 
found in the large intestine, and that the acute symptoms, which are very 
characteristic, maybe traced to the excessive formation of combined sul- 
phates, and are accompanied by the presence of a large amount of indican 
in the urine. Whether the initial cause be exhaustion or mental worry, 
the disordered metabolism of proteids is a likely consequence. This theory 
is borne out by the investigations made by Lewis about seven years ago, 
namely, that there was a very decided reduction in the amount of haemo- 
globin, which in five of his cases varied from 20 to 78 per cent, of the 
standard of healthy blood, although in one of these cases the oligochro- 
masia w T as due to post-partum hemorrhage. In all the five cases there 
was a lowered corpuscular value, and in one maniacal patient a rather 
sudden reduction attended the maniacal outburst. The well-settled con- 
clusions arrived at by Sir Andrew Clark, Solkowski, and others, and 
verified by the writer's cases, show that the absorption of the products of 
bacterial death invariably result not only in diminished haemoglobin, 
but in various alterations in the number and structure of the corpuscles 
themselves. As familiar causes may be mentioned stoppage of the lochia 
and the consequent retention of septic material, subsequent inflammation 
of the uterus itself, and the various accidents of the puerperal state, 
exhaustion after a protracted labor, an extensive rupture of the perineum, 
the suffering incident to the use of instruments, and the formation of abscesses 
of the breast. In a large proportion of cases the cause is to be sought in 
a septic or toxic condition. 

Symptoms. Two forms of puerperal insanity are ordinarily recog- 
nized : maniacal and melancholic, the former being much more common 
than the latter, the percentage varying from 70 to 80 of all the cases, and 
in most instances the excited or depressed state differs but little from the 
familiar derangement due to various non-puerperal causes. There are 
certain peculiarities which are so constant, however, as to be considered 
characteristic by many, notably the erotic manifestations and the destruct- 
iveness. The hallucinations and delusions are of a lively and rapidly 
formed kind, and it may be said that, whether the patient is excited or 

37 



578 PATHOLOGY OF THE PUERPERIUM. 

depressed, painful emotional states are apt to prevail. The melancholia 
may be of slow or rapid formation, and if it has a dominant feature it 
is the tendency to suicide, which is common. 

Irregular mental disturbances which are so brief as not to fall under 
the ordinary heads of insanity, consist in delirium and temporary dis- 
turbances of a confusional nature. There is also in subjects possessing 
the hereditary tendency a variety of insanity characterized by the com- 
mission of impulsive acts, for which the person is very often held respon- 
sible, her ordinary conduct showing very little or no change. Within 
the first week after delivery the woman may present changes and an 
insanity develop of a most dramatic and violent nature. 

There may or may not be a prodromal condition of ill health, mani- 
fested by loss of appetite, indigestion, constipation, and flatulence; but 
such is apt to be the case. The patient's color is usually pale, the pulse 
becomes irritable and quick, and a restlessness is shown which grows, and 
is associated with irritability, tearfulness, and pitiful complaints in regard 
to petty annoyances. Sleep becomes disturbed and broken, and the patient 
is annoyed by bright lights, noises, the slamming of doors, and is apt 
to be querulous and fault-finding. She expresses no interest in her child, 
and, in fact, does not care to see it, and when it is placed by her she is 
either indifferent or asks for it to be taken away. She turns against her 
husband, whom she subsequently accuses of infidelity; she becomes sus- 
picious of those about her, and may say that her food is poisoned and 
refuse to eat it. As the condition deepens so does the excitement, while 
rapidly formed delusions of persecution — which at first are systematized, 
but afterward become disorderly and without foundation — are expressed. 
Auditory hallucinations as well as those of the other senses are constant, 
and lead her to express a fear of injury and contamination. In well- 
developed cases the articles about her are declared to be smeared with 
blood. Evil faces peer at her from every side, and she hears voices 
urging her to kill herself or some one else. Some women manifest 
exceedingly erotic eccentricities of conduct, which amount to nympho- 
mania. 

Refined and gentle women will make indecent proposals and write foul 
scrawls, expose their persons, and subsequently defile themselves and their 
bedclothing with their excrement. There are some cases of slower growth 
where the initial disturbance consists in a stolid silence, with a great deal 
of suppressed excitement which finally bursts forth. Cases are known 
in which women remained absolutely mute for a week or more, concealing 
their delusions, and ultimately, within a remarkably brief space of time, 
became incoherent and violent. In the depressed form of trouble there 
may be slowly developed delusions which sometimes have a religious 
coloring, and such patients are apt to accuse themselves of crimes, believ- 
ing that they are the special objects of divine condemnation and are 
hardly fit to live. It is not at all unusual for such a patient to declare 
that her baby is not her own, or if it is, that it must be destroyed as a 
sacrifice, and that she must herself kill it, which she does. Sometimes, 
as a result of delusion she kills herself, or tries to, and it is not unusual 
for her to do this, believing that she is a burden to her husband and 
friends, although in the majority of cases, as has been said, the puerperal 
insane distrust those about them, and are filled with their own unhappy 



PUERPERAL INSANITY. 579 

importance. The concealed form of the disease is one in which the 
patient may manifest a slight depression which does not reach the dignity 
of simple melancholia, and in which her hysterical conduct or derange- 
ment, regarded, as a rule, as ordinary neurasthenia, in reality disguises a 
most serious psychosis which is appreciated for the first time when some 
sudden and perhaps successful attempt at suicide, or some impulse result- 
ing in destruction of her child or another person, awakens every one to 
the gravity of the masked disease that has perhaps existed for a long 
time. 

The insane crimes of puerperal women are nearly always of a nature 
to suggest an unbalanced mind, and there is none of the concealment 
that belongs to child murder committed by sane persons. 

Regis refers to the fact that homicide is a feature of post-partum 
insanity, while theft and other misdemeanors which imply a sudden 
instigation or a desire to satisfy, are chiefly features of ante-partum 
insanity. 

There is no doubt of the fact that throughout the puerperal state the 
woman has diseased appetites and impulses, and though they may not 
rank very high as evidences of mental deterioration, and may disappear 
entirely after the re-establishment of menstruation, they at some time or 
other find expression in disorderly acts, some being of a criminal nature. 
Destruction of property, incendiarism, and the impulsive propensity to 
steal are not infrequently manifested, and abortive attempts at suicide lead 
to newspaper publicity and possibly to legal prosecution. So far as the 
physical evidences of puerperal insanity are concerned, we find little that 
is distinctive or is not associated with the ordinary insanities. The indi- 
cations of malnutrition in the acute, excited and depressed psychoses are 
generally exaggerated, and those signs of loss of tone of the bodily 
functions which are the expressions of exhaustion appear much earlier 
than they otherwise usually do. Early and obstinate constipation, 
heavily loaded urine, and other indices of gastro-enteric disturbance 
usually commence almost as soon as, and often before, the excitement 
is at all marked, and may eventually resemble the so-called typhoid 
symptoms of various states of exhaustion. Pallor is a characteristic 
appearance which is common to certain other toxic insanities; the skin 
often has a glossy, drawn look, and the breath the so-called starvation 
odor. Some women at a very early time rapidly sink into a delirious 
condition, with occasional periods of consciousness, but without any rise 
of temperature, the state being erroneously called puerperal fever; in 
reality it is a toxaemia which varies in intensity of expression with the 
rapidity of absorption and the virulence of the septic poison. Sometimes 
the mental symptoms, as has been said, are immediately connected with 
the stoppage of the lochial discharge; but the discontinuance of the 
latter is more often an effect than a cause. 

Some writers regard stuporous melancholia to be the type belonging 
specially to puerperal insanity, which, however, is a view the writer can 
hardly take, unless the familiar mute form of the disease is to be so 
regarded; this seems improbable, as the subjects of the latter so often 
eventually express a certain intensity of feeling which undoubtedly 
exists in the earlier stages in a repressed form, even when the patient is 
most silent. 



580 PATHOLOGY OF THE PUERPERIUM. 

Prognosis. In a large number of cases there is a comparatively prompt 
recovery, especially in puerperal mania. The prognosis is not nearly so 
good in melancholia; but, of course, in both conditions much depends 
upon the treatment. Where an hereditary groundwork exists the situ- 
ation becomes much more grave, and the danger of non-recovery is 
increased by the occurrence of two or more attacks. Regis does not 
regard any form of puerperal insanity to be as curable as simple general- 
ized insauity. He considers that the forms occurring during gestation or 
labor are much more likely to get well than when the affection develops 
at a later period, believing that the insanity of lactation is much more 
serious. 

So far as time is concerned, much depends upon the duration of the 
symptoms and upon the age of the subject. If the physician adopts 
prompt measures the condition may be cut short within a brief space 
of time, especially if the patient be a young woman; but if, as is often 
the case, she enters an asylum after the existence of a mania or melan- 
cholia for several months, her prospects are rather bad, for a certain 
mental involution has taken place which is likely to be permanent 
and progressive. As to age, it may be held that if puerperal insanity 
develops in a woman over thirty the prognosis is much more unfavorable. 
Lewis's figures, which may be taken, show that the recovery-rate may 
even reach a percentage of 80, while 8.5 per cent, represents the mor- 
tality. Of the 80 per cent, who recovered the greater number got well 
before the sixth month, there being 37 out of QS cases; the others slowly 
recovered. It would also appear from his tables and those of Clouston 
that the sooner patients entered the asylum and were treated, the more 
rapid was their recovery. So far as the writer's experience is con- 
cerned, those who manifested suicidal tendencies or in whom the delusions 
were fixed and limited presented a form of the disease which is the least 
curable. On the other hand, in the ordinary cases, where the delusions 
and hallucinations are general and unstable, the prognosis is fairly good. 
Should a case progress, the termination of dementia is not usually so 
rapid as that of other forms, in this respect resembling the limited delu- 
sional insanities. 

Treatment. Very much tact and care are needed in the early manage- 
ment of puerperal insanity, which is often difficult because of the situa- 
tion of the patient and the prejudices of the family. The interference 
of an anxious husband is too often apt to tie the hands of a physician 
and to prevent him from adopting and using the wise measures of 
restraint that are demanded. Much of this may arise from the non- 
recognition of the serious nature of the complication, the friends of the 
woman believing it to be some temporary disturbance which may be an 
unimportant symptom of the puerperal condition, that will disappear 
in a few days. The early irritability and malaise of the woman are 
rarely appreciated, and the solicitous husband is apt to force his society 
upon his wife or to insist upon leaving the child in bed with her, despite 
her expressions of disgust or indifference. Anxious and sympathetic 
friends insist upon paying visits, and injudicious clergymen attempt a 
moral reform and proffer religious consolation, which has either no effect 
at all, or a harmful one, upon the already deranged woman. One of the 
first duties of the physician is to leave her alone with her nurses, who 



PUERPERAL INSANITY. 581 

should be competent and experienced, and isolation should be rigidly 
enforced. 

The isolation of the patient should last for a considerable time, and 
even when committed to an asylum it is best that she should be kept away 
from other patients, especially those who are apt to excite or eucourage 
her delusions. 

All things being considered, there is no reason why a patient of this 
kind should be removed from home, even if it were proper for her to leave 
her bed. But where proper facilities for nursing and restraint are not 
available, removal to a well-ordered asylum should be insisted upon as 
soon as the local conditions will permit and the diagnosis is made with 
certainty. It seems hardly necessary to refer to the importance of re- 
moving every possible agent with which the patient might injure herself 
or others; but the frequent tragedies that so often occur through neglect 
of this precaution must excuse a repetition of what may seem to be 
trivial advice. The patient should not be left a moment alone; all window- 
shutters should be properly fastened, and the room should be stripped of 
unnecessary furniture and especially pictures. When the patient is able 
to leave her bed a floor should be devoted, if possible, to her accommo- 
dation, one room being reserved for day use and the other for sleeping. 
It is always advisable to have a sufficient number of nurses to avoid 
fatiguing struggles, and instruments of restraint should not be made use 
of except in very rare instances. Where the mania, however, fol- 
lows exhausting hemorrhage, and where the heart's action is irritable 
and weak, it is, of course, preferable to keep the patient in a recumbent 
position, which may be done by a combination camisole or a strong sheet 
properly fastened at the sides and foot of the bed. Some sort of mechan- 
ical restraint is permissible in destructive cases, and is not nearly so 
exhausting or trying as the injury that is unavoidably done by even 
the most humane nurses in their efforts to control the patient. 

One of the first forms of medicinal treatment consists in the correction, 
if possible, of the intestinal condition as well as that of the uterus and 
vagina. Observers generally call attention to the necessity of the removal 
of sources of peripheral irritation or local infection. An inconsiderable 
focus of septic infection may give rise to an elevation of temperature, 
and is often associated with ill-smelling discharge and some tenderness; 
it is hardly necessary to say that all retained septic material should be 
carefully removed, either by the curette or some other means, and the 
mucous membrane of the uterus and vagina should be disinfected. It is 
always well to give the patient a full dose of calomel and soda, which is 
to be followed up by such intestinal antiseptics as the salicylate of soda 
or naphthalin, and the lower bowel as well as the vagina and uterus 
should be douched w r ith solutions of borax, carbolic acid, or the hypo- 
chlorite of sodium. 

These douches should be given frequently, and large amounts of liquid 
are to be employed; at the same time the perineum and external organs 
of generation are to be washed frequently with antiseptic solutions, and 
proper precautions are to be taken when the bowels are moved. In some 
instances the use of dilute hydrochloric acid and nux vomica is of 
benefit, and at a later stage, when it is possible, lavage is suggested. In 
some patients the condition of exhaustion and depression is very great, 



582 PATHOLOGY OF THE PVERPERIUM. 

and the administration of strychnine, either hypodermically or by the 
mouth, is attended with the best results. Of course, one of the earliest 
indications is the provision of remedies to promote sleep and to calm the 
excitement which is so pronounced. Oar knowledge of the value of 
intestinal antiseptics leads us to expect most happy effects from the in- 
ternal use of naphthalin, and MacPherson found that many of his most 
excited patients became calm and slept well after a few doses of naph- 
thalin, which may be administered in quantities of five grains three times 
a day, and, if necessary, be increased to fifteen or twenty grains at a 
dose; should a special hypnotic be needed, there is none better than the 
hydrobromate of hyoscin, which may be given in doses of from yJ^ to 
-J- of a grain, to be repeated, if necessary, until the physiological effects 
are attained. Should this not succeed, the only other remedy worthy of 
much confidence is morphine, though chloral, the bromides, chloralamide, 
or paraldehyde may be tried. While chloral in light cases is better than 
the last two drugs mentioned, it should never be given to debilitated 
patients, and where the proportion of blood-corpuscles and the percent- 
age of haemoglobin are low, it, as well as the bromides, is contraindi- 
cated. In such examples it is much better to prescribe some such drug 
as paraldehyde or chloralamide. The writer does not recommend sul- 
phonal, trional, or others of the series, which sometimes produce sur- 
prisingly bad after-effects. In some restless cases where there is much 
debility, sleep may be produced by large doses of the tincture of digitalis 
or by alcohol. Hydrotherapy is of decided advantage as an adjunct, 
and a hot bath or a cold pack will often succeed where drugs fail. As 
has been said, the feature of puerperal insanity is physical exhaustion 
and malnutrition. It is, of course, necessary to put the patient upon a 
simple nutritious diet, which should consist for a long time of nothing 
but milk in generous quantities, and in the early history of the case it is 
not wise to give eggs or meat or substances which are apt to be imper- 
fectly digested in the intestines. Iron, arsenic, or the gelatinous prepa- 
ration of the phosphate of lime made by Leroy, of Paris, may be used 
at a later stage, with the effect of shortening convalescence. 

So far as mental management is concerned, it is best not to resort to 
any systematic or aggressive measures, the patient being simply protected 
and furnished with congenial amusement, including free exercise in the 
open air. 



CHAPTER XXVII. 

PUERPERAL INFECTION. 

By the term puerperal infection we understand the various morbid 
conditions of the female genital tract and the systemic affections depend- 
ent thereon which result from infection during labor or the puerperium 
by various micro-organisms. These infections are generally designated 
as puerperal fever, but we prefer to avoid the term, as it still suggests 
to many the old idea of the essentiality of the affection, which was so 
strongly urged in this country by the late Fordyce Barker. 1 It also 
emphasizes the febrile phenomena of the affection, instead of laying 
stress upon its infectious nature aud the consequent responsibility of the 
obstetrician and his assistants. We also prefer the term puerperal infec- 
tion to that of puerperal septicaemia, or sepsis, which has lately come 
into frequent use ; for in many instances the infection results in per- 
fectly localized inflammatory processes to which these terms cannot 
be applied without violating the established rules of diction. 

It is probable that puerperal infection has occurred almost as long as 
children have been born, and passages may be found in the works of 
Hippocrates, Galen, Avicenna, and many other of the older writers which 
clearly referred to it. The term puerperal fever, however, is of com- 
paratively recent origin, and was introduced by Willis in 1676, who 
referred to it as " febris puerperaruni." The English term puerperal 
fever, it appears, was first employed by Strother 2 in 1718, and has con- 
tinued in use ever since. 

The ancients regarded the affection as the result of retention of the 
lochia; and this remained the prevalent explanation for its occurrence 
until a comparatively recent date. It was not until the early part of the 
seventeenth century that other explanations were offered, when Plater 
showed that it was essentially a metritis, and was followed in the next 
century by Puzos with his milk metastasis theory. 

From the time of Plater until Semmelweiss 3 (1847) demonstrated its 
identity with wound infection, or, we may say, until Lister demonstrated 
the value of antiseptic surgery, all sorts of theories were suggested con- 
cerning its origin and nature, the consideration of which would occupy 
the entire space allotted to us. And we would, therefore, refer those who 
are interested in the history of the affection to the monographs of Eisen- 
mann ( Wund und Kindbettfieber , Erlangen, 1837) and Silberschmidt (His- 
torische-kritische Darstellung der Pathologie des Kindbettfiebers, Gekronte 
Preisschrift, Erlangen, 1859, 131 pp.). 

Organisms Causing Puerperal Infection. In 1847, Semmelweiss, 4 then 
an assistant in the Vienna Lying-in Hospital, began to study the cause of 
the frightful mortality attending the confinement of women in that hospital, 
as compared with the small number of women succumbing to puerperal 

1 Barker. The Puerperal Diseases, third edition, 1874. 
a Strother. Critical Essay on Fevers. Loudon, 1718. 

3 Semmelweiss. Die Aetiologie, der Begriff u. die Prophylaxis des Kindbettfiebers Pest. Wien u. 
Leipzig, 1861. 

4 Semmelweiss. Op. cit. 

(583) 



584 PATHOLOGY OF THE PUERPERIUM. 

infection when delivered in their own homes. As a result of his observa- 
tions, he concluded that puerperal infection was a wound-infection, and 
was due to the introductiou of septic material by the examining tiuger. 
He accordingly obliged every one to disinfect his hands with chlorine 
water before examining the parturient woman, and had the pleasure of 
seeing the mortality fall from 10 per cent, or more to about 1 per cent. 
In spite of the excellent results, his work was scoffed at by many of the 
most prominent men of his time; and it was not until after the discov- 
eries of Lister and the development of bacteriology that his services 
were thoroughly appreciated. Trousseau/ in 1858, recognized the same 
fact, and pointed out the identity of puerperal and wound infection in 
the following words: " Quelque chose de specifique s'ajoute a la plaie 
placentaire, a la plaie chirurgicale." 

We shall now briefly consider the organisms which have been proved 
to be causes of puerperal fever. 

(«) Streptococcus. It has been abundantly and conclusively demon- 
strated by many excellent observers that the streptococcus is the usual 
cause of the epidemic and fatal forms of puerperal infection. Before 
the development of cultural methods streptococci were demonstrated by 
many observers in the tissues of women dead of puerperal infection. 
They were first observed in 1865 by Mayerhofer, 2 whose findings were 
confirmed bv Coze and Feltz, 3 Recklinghausen, 4 Waldeyer, 5 Klebs, 6 
Orth, 7 Heiberg, 8 and Landau. 9 To Pasteur 10 (1880) belongs the credit 
of having first cultivated streptococci from cases of puerperal infec- 
tion, when he designated them as " chapelets en grains." He was 
assisted in this work by Doleris, 11 who carried it on still further and was 
able to demonstrate that streptococci were the usual infectious agents, but 
that staphylococci, and in rare cases bacilli as well, played a part in the 
production of the infection. The researches of Pasteur and Doleris were 
soon confirmed by Fraenkel, 12 Iovanovic, 13 Lomer, 14 Winckel, 15 Bumm, 16 
Doederlein, 17 "Winter, 18 Ott, 19 Czerniewski, 20 Widal, 21 and all subsequent 
observers ; so that at the present time it is universally admitted that 
the streptococcus pyogenes is the direct causative agent in most severe 
cases of puerperal infection. 

1 Trousseau. Quoted by Doleris. See note 11. 

2 Mayerhofer. Zur Frage nach der Aetiologie der Puerperalprocesse. Monatsschrift f. Geburtskunde, 
1865, xv. 112. 

3 Coze and Feltz. Gazette raed de Strassburer, 1869, p. 30. 

4 Recklinghausen. Cent. f. med. Wissenschafteu, 1871, 713. 

5 Waldeyer. Ueber das Vorkommen von Bakterien bei der dipbtherischen Form des Puerperal- 
fiebors. Arch. f. Gyn., 1872, iii. 293. 

6 Klebs. Archiv f. ex per. Path., Bd. v. p. 417. 

7 Orth. Virchow's Archiv, lviii. 441. 

8 Heiberg. Die puerperalen und pyamischen Processe, 1873. 

9 Landau. Ueber puerperalen Erkrankuugen. Arch. f. Gyn., 1874, vi. 147. 

10 Pasteur. Septicemie puerperale. Bull, de l'Acad. de Med., 1879, 260. 271. 

11 Doleris. Essai sur la pathogenie et la therapeutique des accidents infectieux des suites de 
couches. These de Paris, 1880. 

12 Fraenkel. Quoted by Lomer. See below. 

13 Iovanovic. Quoted by Lomer. See below. 

14 Lomer. Ueber den heutigen Stand der Lehre von der Infectiontragern bei Puerperalfieber. Zeit. 
f. Geb. u. Gyn., 1884. x. 366. 

15 Winckel. Zur Lehr von dem internen puerperalen Ervsipel. Verh. d. deutschen Ges. f. Gyn., 
1S86. 78. 

16 Bumm. Die puerperale Wundinfektion. Cent. f. Bakteriol., 1887, ii. 343. 

17 Doederlein. Untersuchung iiber das Vorkomraenvon Spaltpilzen in den Lochien des Uterus und 
der Vagina gesuuder und kranker Wochnerrinnen. Arch. f. Gvn., 1887, xxxi. 412. 

18 Winter. Die Mikrobrganisnien in Genitalkanal der gesunden Fraun. Zeit. f. Geb. u. Gyn., 1888. 
xiv. 443. 

' 9 Ott. Zur Bakteriologie der Lochen. Arch. f. Gyn., 1888, xxxii. 436. 

20 Czerniewski. Zur Frage von den puerperalen Erkrankungen. Eine bakteriologische Studie. Arch, 
f. Gyn . 1888,,xxxiii. 73. 

21 Widal. Etude sur 1'infection puerperale. These de Paris, 18S9. Infection puerperale et phleg- 
matia alba dolens. Gaz. des hop., 1889, 565. 



PUERPERAL INFECTION. 585 

(b) Staphylococcus. While streptococci are usually the causative 
agents iu puerperal infection, it has gradually been demonstrated that 
they are not necessarily the only organisms which may be concerned in 
its production, and it has been clearly shown that most of the pus- 
producing organisms which may be concerned in wound-infection may, 
likewise, occasionally give rise to puerperal infection. 

Brieger, 1 in 1888, was the first to demonstrate that puerperal infection 
might be due to staphylococci, when he reported autopsies upon seven 
cases, in five of which he was able to demonstrate the staphylococcus 
aureus. Doleris, 2 in his thesis of 1880, stated that he was able to culti- 
vate in pure culture a coccus which was arranged in groups or bunches, 
but it was not until 1894 3 that he stated definitely that they were staphy- 
lococci. The observations of Brieger 4 were soon confirmed by other 
observers, among whom may be mentioned Czerniewski, 5 Fehling, 6 
Haegler, 7 Doederlein, 8 Widal, 9 Mironow, 10 Netter and Bounaire, 11 Sabrazes 
and Faquet, 12 Kronig, 13 and Striinckman. 14 

It was stated by Fehling 15 and Haegler 16 that staphylococci usually 
give rise to mild forms of infection. But this is not borne out by the 
observations of other authors. Occasionally mixed infections with the 
staphylococcus and streptococcus are observed, as reported by Doeder- 
lein 17 and Bar and Tissier. 18 It appears that the staphylococcus aureus 
is the variety observed in puerperal infection, while the albus and citreus 
play little or uo part in its production. 

(c) Gonococcus. It has long been believed by clinicians that gonor- 
rhoea not infrequently plays a part in the production of puerperal infec- 
tion. But it was not until 1893 that Kronig 19 adduced bacteriological 
proof of its action. He then reported nine cases of mild infection, in 
all of which he was able to obtain pure cultures of gonococci from the 
uterine lochia. In a recent communication 20 he states that he was able 
to cultivate the gonococcus in 50 cut of 179 cases presenting febrile puer- 
peria, and has thus shown that it plays an important part in the pro- 
duction of puerperal disease. None of these cases resulted in death, and 
the great majority recovered spontaneously. 

1 Brieger. Ueber bakteriologische Untersuchungen bei einigen Fallen von Puerperalfieber. CharitS 
Annalen, 1888, xiii. 198. 

2 Doleris. Essai sur la pathogenie et la therapeutique des accidents infectieux des suites de couches. 
These de Paris, 1880. 

3 Doleris. Inflammation puerperale. Nouve. Archives d'obst. et de gyn., 1894, ix. 97-122, 142-161. 

4 Brieger. Ueber bakteriologische Untersuchungen bei einigen Fallen von Puerperalfieber. Charite 
Annalen, 1888, xiii 198. 

5 Czerniewski. Zur Frage von den puerperalen Erkrankungen. Eine bakteriologische Studie Arch, 
f. Gyn , 1888, xxxiii. 73. 

6 Fehling. Ueber Selbstinfektion. Verhand. deutsche Ges. f. Gyn., 1889, Freiburg. 

7 Haegler. Quoted by Fehling. Physiologie und Path, des Wochenbetts. Stuttgart, 1890. 

8 Doederlein. Klinisches und Bakteriologisches liber eine Puerperalfieber-epidemie. Arch. f. Gyn., 
1891. xl. 99. , 

9 Widal. Etude sur l'infection puerperale. These de Paris, 1889. Infection puerperale et phleg- 
matia alba dolens. Gaz. des hop., 1889, 565. 

10 Mironow. Ueber die Ursachen der puerperalen Erkrankungen. D. I. Charkow, 1889. Referat. 
Cent. f. Gyn , 1891, 678-80. 

11 Netter and Bonnaire. Quoted by Doleris, No. 36. 

12 Sabrazes and Faquet. Infection puerperale staphylococcique, etc. Gaz. des hop., 1894, 1039-41. 

13 Kriinig. Aetiologie und Therapie der puerperalen Endometritis. Cent. f. Gyn., 1895,422-32. 
Discussion iiber Endometritis. Verb. d. deutschen Ges. f. Gyn., 1895, 498-502. 

14 Strfinckmann. Zur Bacteriologie der Puerperal-infection. Berlin, 1898. 

15 Fehling. Ueber Selbstinfektion. Verhand. deutsche Ges. f. Gyn., 18S9, Freiburg. 

16 Haegler. Quoted by Fehling. Physiologie und Path, des Wochenbetts. Stuttgart, 1890. 

17 Doederlein. Klinisches und Bakteriologisches fiber eine Puerperalfieber-epidemie. Arch. f. 
Gyn., 1891, xl. 99. 

18 Bar and Tissier. La Semaine med., 1896, 155. Serotherapie dans l'infection puerperale. L'Ob- 
stetrique, 1896, 97-128 and 204-217. 

19 Kronig. Vorlaufige Mittheilung fiber Gonorrhoea im Wochenbett. Cent. f. Gyn., 1893, 157. 

20 Krdnig. Aetiologie und Therapie der puerperalen Endometritis. Cent. f. Gyn., 1895, 422-32. 
Discussion fiber Endometritis. Ver. d. deutschen Ges. f. Gyn., 1895, 498-502. 



586 PATHOLOGY OF THE PVERPERIUM. 

Leopold 1 also reports similar cases, and Maslowsky 2 and Neumann, 3 
in two recent articles, state that they were able to demonstrate the gono- 
coccus in the tissues in cases of endometritis deciduse. It is generally 
believed that gonorrhceal infection in the puerperium pursues a favorable 
course. But in very rare instances a gonorrhceal septicaemia may result, 
which will lead to the death of the patient, as in a case recently reported 
by Harris and Dabney. 4 

(d) Bacilli's Coli Communis. In the writer's article 5 upon puer- 
peral infection from a bacteriological point of view (1893\ it was stated 
that von Franque 6 had cultivated the colon bacillus from a case of 
puerperal infection, and the belief was expressed that it would be demon- 
strated more frequently in the future. Subsequent work has amply 
fulfilled this prediction, and we can now point to a long series of cases 
due to this organism. .4 priori, this is what should be expected when 
we consider the proximity of the genital tract to the rectum and the 
ease with which contamination may occur when the obstetrician infringes 
the strict rules of asepsis. 

Some idea of the abundance of the colon bacillus may be gained by 
the consideration of the figures of several French observers ; thus,Vignal" 
states that one decigramme of feces contains about twenty millions of 
colon bacilli; and Gilbert and Dominici s estimate that from twelve to 
fifteen billions are daily excreted with the feces. It thus becomes appa- 
rent that the examining finger cannot avoid contamination with these 
organisms if it comes in contact with a non-disinfected perineum. 

Infection with the colon bacillus has been observed by Mironow, 9 
Ahlfeld, 10 Eisenhardt, 11 Demelin, 12 Parmentier, 13 Gebhard, 14 Chantemesse 15 
and AVidal, Marmorek, 16 Charpentier/ 7 Kronig, 15 Bar and Tissier/ 9 and 
myself in many cases. 

Gebhard 20 demonstrated its presence in seven cases of tympania uteri, 

1 Leopold. Ueber gonorrhoisches Fieber in Wochenbett bei einer innerlich nicht untersuchten 
Gebarenden. Cent. f. Gyn., 1893. 675. 

2 Maslowsky. Zur Aetiologiedervorzeitigen Ablosung der Placenta voni normalen Sitz. Monats. 
f Geb. u. Gyn., 1896, iv. 212-218. 

a Xeumarin. Ueber puerperalen Uterusgonorrhcea. Monats. f. Geb. u. Gyn., 1896, iv. 109-116. 

4 Harris and Dabney. Report upon a Case of Gonorrhoea 1 Endocarditis in a Patient dying in tbe 
Puerperium. Bull. Johns Hopkins Hospital, 1901, xii. 68-76. 

5 Williams. Puerperal Infection Considered from a Bacteriological Point of View, with Special 
Reference to the Question of Auto-infection. Amer. Journ. MedTSci., July, 1893. 

6 v. Franque. Bacteriologische Untersuchungen bei normalen und fieberhaftem. Wochenbett 
Zeit. f. Geb. u. Gyn.. 1S93. xxv. 277. 

7 Vignal. Sur Taction des micro-organisms de la bouche et des matieres fecales. Comptes-rend. 
de la Soc. de Biol., Aout., 1887. 

8 Gilbert and Dominici. Recherches sur le nombre des microbes du tube digestif. Semaine med., 
1894, p. 76. 

9 Mironow. Ueber die Ursachen der puerperalen Erkrankungen. D. I. Charkow, 1889. Referat. 
Cent. f. Gyn., 1891. 678-80. 

10 Ahlfeld. Beitrage zur Lehre vom Resorptionsfieber in der Geburt und im Wochenbette und von 
der Selbstinfektion. Zeit. f Geb. u. Gyn., 1893, xxvii. 466-519. 

11 Eisenhardt. Puerperale Infektion mit todlichen Ausgang verussacht durch Bakterium coli 
commune. Arch. f. Gyn., 1894, xlvii. 189-202. 

12 Demelin. Quoted bv Barbier. Des pseudo-infections puerperales d'origine intestinale. These 
de Paris, 1894. 

13 Parmentier. Quoted by Barbier. Des pseudo-infections puerperales d'origine intestinale. 
These de Paris. 1894. 

14 Gebhard. Bacterium coli commune aus Fallen von Tvmpania uteri gezuchtet. Verh. deutsche 
Ges. f. Gyn., 1893, 305. 

15 Chantemesse. Bulletin med., 1891. p. 1139. 

16 Marmorek. Le streptocoque et le serum antistreptococcique. Annales de l'lnst. Pasteur, 1895, 
ix. 593-620. 

17 Charpentier. Serotherapie antistreptococcique applique au traitement de la fievre puerperale. 
La Semaine gyn., 1896, 89-92, Xo. 12. 

18 Kronig. Ueber Fieber intra-partum. Cent. f. Gyn.. 1894, 749. 

19 Barr and Tissier. La Semaine med., 1896, 155. Serotherapie dans l'infection puerperale. L'Ob- 
stetrique. 1896, 97-128 and 204-217. 

tebhard. Bacterium coli commune aus Fallen von Tvmpania uteri gezuchtet. Verh. deutsche 
Ges. f. Gyn., 1893, 305. 



PUERPERAL INFECTION. 587 

either alone or in combination with other organisms; and Galtier 1 states 
that it is the organism most frequently concerned in its production. 

In not a few cases it is associated with the streptococcus, as has been 
observed by Marmorek, 2 Ckarpentier, 3 Bar and Tissier, 4 and the writer 
the former observers stating that the combination appears to augment 
the virulence of the streptococcus and gives rise to very intense affec- 
tions. Whether the future will demonstrate the accuracy of their state- 
ments remains to be seen. 

(<?) Bacillus Diphtheria. Until very recently it was believed that 
the "diphtheritic deposits" upon the vagina and the interior of the 
puerperal uterus were due to the streptococcus alone, and had nothing to 
do with true diphtheria. But the recent observations of Nisot, 5 Bumm, 6 
and the writer 7 show that this is not always the case, for we reported cases 
in which we were able to cultivate the Klebs-Loeffler bacillus from the 
diphtheritic membrane in the vagina aad to cure the affection by the use 
of the anti-diphtheritic serum. 

(/) Pneumococcus. Cases have been reported by Weichselbaum, 8 
Czemetschka, 9 Schuhl, 10 and Vesque, 11 in which the micrococcus lanceo- 
latus has been demonstrated in the puerperal uterus. In the case 
reported by the former the genital infection was the primary lesion, 
while in the latter case it was the result of systemic infection. And 
Bar and Tissier 12 have lately reported a case of sepsis in which it was 
associated with the streptococcus. 

(g) The Bacillus Aerogenes Capsulatus (Gas Bacillus). As 
our knowledge concerning the gas bacillus of Welch has become more 
accurate, it has been shown that it may also occasionally be concerned in 
puerperal infection. In 1896 the writer observed a case in which its 
presence was demonstrated, and which was described by Dr. Dobbin in 
the Bulletin of the Johns Hopkins Hospital. Briefly stated, the case was 
as follows: The aid of the out-patient obstetric department of the Johns 
Hopkins Hospital was solicited in the case of a Bohemian woman with 
a generally contracted pelvis, who had been in labor for some three to four 
days under the care of a midwife. When the writer saw the patient he 
found the head of a macerated child firmly engaged in the superior strait, 
with the uterus tetanically contracted. A fetid dark-colored discharge, 
which contained many gas bubbles, was escaping from the vagina with a 
crackling sound. Owing to the softened condition of the child's head, 
several futile attempts at delivery were made, and we were finally forced to 
deliver it with Tarnier's basiotribe. The mother was profoundly infected 

1 Galtier. De l'infection primitive du liquide amniotique apres la rupture prematuree des mem- 
branes de l'oeuf humain. These de Paris, 1895. 

2 Marmorek. Le streptocoque et le serum antistreptococcique. Annales de l'Inst. Pasteur, 1895, 
ix. 593-620. 

3 Charpentier. Serotherapie anti-streptococcique applique au traitement de la fievre puerperale. 
La Semaine gyn., 1896, 89-92, No. 12. 

4 Bar and Tissier. La Semaine med , 1896, 155. Serotherapie dans l'infection puerperale. L'Ob- 
stetrique, 1896, 97-128 and 2(4-217. 

5 Nisot. Diphtherie vagino-uterine puerperale. Serotherapie guerison. Annales de Gyn., 1896, 
xlv. 259. 

e Bumm. Ueber Diphtherie und Kindbettneber. Zeit. f. Geb. u. Gyn , 1895, xxxiii. 126-136. 

7 Williams. Puerperal Diphtheria. American Journal of Obstetrics, August, 1898. 

a Weichselbaum. Wien. klin. Wochea., 1888, No. 28. 

9 Czemetschka Znr Kenntniss der Patho^enese des puerperalen Infektion (Metrolymphangitis post 
partum) als Metastase anderweitiger durch Diplococcen bedingter Emrankungen. Prager med. 
Wochen.,1891, xix. 233. 

i° Schuhl. TJne epid£mie d'infection puerperale a pneumocoques. Presse mexL, Aug. 21, 1897. 

11 Vesque. Des infections puerpe>ales non-streptococciques. These de Nancy, 1899. 

12 Bar and Tissier. Serotherapie dans l'infection puerperale. L'Obst£trique, 1S96, 97-128 and 
204-217. 



588 PATHOLOGY OF THE PUERPERIUM. 

at the time of delivery, and died the next day. A few hours after death 
the body rapidly became intensely swollen by the development of gas 
in the subcutaneous tissues, and soon nearly doubled its original size. 
The same changes were observed in the foetus and in the placenta, and 
we were able to demonstrate the presence of the gas bacillus in the foetal 
and placental tissues, as well as in the uterine lochia. Unfortunately, 
no autopsy was allowed upon the mother, and we were, therefore, unable 
to say to what extent the organisms had penetrated into her tissues. 

Well-authenticated cases of infection with this organism have been 
reported by Stewart, 1 Ernst, 2 Norris, 3 Woods, 4 Halban, 5 and others, and 
the entire literature upon the subject was exhaustively reviewed by 
Welch 6 in 1900. 

Cases have also been reported by Kronig, 7 Doleris, 8 Lindenthal, 9 and 
others, which were probably due to the same organism. 

It is important to remember that the gas-bubbles which are found in 
the blood-vessels of women, who were supposed to have perished from the 
entrance of air into the uterine sinuses, are not infrequently the product 
of the bacillus in question. Attention was first directed to this point 
by Dobbin, 10 and was still further insisted upon by Welch, 11 so that at 
present we do not consider that one is justified in making the diagnosis 
of air-embolism, unless careful bacteriological examination has demon- 
strated the absence of the gas bacillus. 

(h) Bacillus Typhosus. 
latecl the typhoid bacillus, streptococcus, staphylococcus aureus, and an 
unidentified anaerobic gas-producing bacillus from the uterine lochia of 
a woman who was admitted to the Johns Hopkins Hospital on the fifth 
day of the puerperium, with high fever. Her blood possessed the 
characteristic Widal reaction, but all the usual symptoms of typhoid 
fever were absent. The temperature fell to normal on the thirteenth 
day, and did not rise again. We are inclined to believe that the typhoid 
bacilli were introduced into her uterus by the midwife, along with other 
organisms, opportunity being afforded by the fact that she was delivered 
upon the same bed upon which her husband had died of typhoid fever 
a few days previously. And as they were ignorant Bohemians, it is 
quite conceivable how an infection may have occurred. 

A somewhat similar case has been reported by Blumer, 14 in which the 
autopsy revealed an unsuspected typhoid fever. 

1 Stewart and Baldwin. Bacillus aerogenes capsulatus. Columbus Med. Journ., Aug., 1893. 

2 Ernst. Ueber einen gasbildenden Anaeroben in menschlichen Korperund seine Beziehung 
zur Sehaumleber. Virchow's Arcb., cxxxiii. Heft 2. 

3 Norris. A Report of Six Cases in which the Bacillus aerogenes capsulatus was Isolated. 
Amer. Journ. Med. Sci., Feb., 1899. 

4 Wood. Puerperal Infection Caused by the Bacillus aerogenes capsulatus. Med. Record, April 
15, 1899. Ref. Cent. f. Gyn., 1900, p. 436, No. 16. 

6 Halban. Uterus emphvsem und gas-sepsis. Monatsschr. f. Geb. u. Gyn., 1900, xi 88-122. 

6 Welch. Boston Med. Jour., 1900. 

7 Kronig. Discussion iiber Endometritis. Verh. d. deutschen Ges. f. Gyn., 1895, 498-502. 

8 Doleris. Inflammation puerperale. Nouv. Arcb. d'obstet. et de gyn , 1894, ix. 97-122, 142-162. 

9 Lindenthal. Beitriige zur Aetiologie der Tympania uteri. Monatsschr. f. Geb. u. Gyn., 1898, 
vii. 269-86. 

10 Dobbin. Puerperal Sepsis due to Infection with the Bacillus aerogenes capsulatus. Bull. 
Johns Hopkins Hosp., Feb. 1, 1897. 

11 Loc. cit. 

12 Dobbin. A Case of Puerperal Infection in which the Bacillus typhosus was Found in the 
Uterus. Amer. Journ. Obst., 1898, xxxviii. 185-19S. 

13 Williams. Ein Fall von puerperaler Infection, bei dem sich Typhus-bacillen in den Lochien 
fanden. Centralbl. f. Gyn., 1898, No. 34. 

14 Blumer. A Case of Mixed Puerperal and Typhoid Infection, in which the Streptococcus and 
Tvphoid Bacilli were Isolated both from the Blood and the Uterine Cavity. Amer. Journ. Obst., 
1899, xxxix. 42-50. 



PUERPERAL INFECTION. 589 

(i) Bacillary Sepsis. Isolated cases reported by Fraenkel, 1 Do- 
leris, 2 Widal, 3 Mixius, 4 Goldscheider, 5 and others tend to show that 
certain cases of fatal infection may be due to bacilli with whose prop- 
erties we are as yet unacquainted. But the bacteriological w T ork upon 
which these statements are based is not of a character to enable us to 
be at all sure about the organisms in question, much less to classify 
them. At the same time, bacteriological examination of the uterine 
lochia in all cases of fever in the puerperium, as carried out by Kronig 6 
and the writer, clearly show that many bacteria, with which we are as 
yet unfamiliar, may take part in the process. 

(J) Saprsemia. Beside the cases in which the infection is due to the 
growth and extension of micro-organisms within the body, there is a 
large class of cases in which the symptoms are due to the absorption of 
toxic products produced by organisms within the uterus or elsewhere 
in the generative tract which do not make their way into the blood- 
current. To this form of infection Matthews Duncan, some years ago, 
applied the term " saprsemia," which has continued in use ever since. 
It is usually thought to be due to the invasion of the uterus by putre- 
factive organisms, with whose properties we are as yet almost totally 
unfamiliar. 

There is no doubt that the term has been greatly abused, and that many 
cases have been included under it which really were due to infection with 
the ordinary pyogenic organisms, and at the present time we are hardly 
justified in considering a case as saprsemic unless the lochia have 
been examined bacteriologically and found to be free from pyogenic 
organisms. 

This statement is borne out by the observations of Buram, 7 who found 
streptococci in eight out of eleven cases which were clinically designated 
as saprsemia. Von Franque 8 was, likewise, able to cultivate streptococci 
in pure culture from a case which exhibited the clinical picture of saprse- 
mia, and as the result of his observations stated that "saprsemic fever 
in the puerperium is extremely rare, and it should only be diagnosed 
when an accurate biological examination of the uterine lochia has demon- 
strated the absence of pathogenic and the presence of saprophytic organ- 
isms," 

The organisms entering into the causation of saprsemia are mostly of 
an anaerobic nature, and, therefore, cannot be cultivated in the usual cul- 
ture media. Many of them are gas producers, and thus cause the frothy, 
ill-smelling secretion which is so characteristic of these cases. There is 
certainly a great variety of organisms which may be concerned in the 
production of saprsemia, though only a few have as yet been isolated. 
Thus, Bumm 9 was able to cultivate from a case an anaerobic bacillus, 

1 Fraenkel. Quoted by Lomer. See below. 

2 Doleris. Inflammation puerperale. Nouv. Archiv. d'obstet. et de gyn., 1894, ix. 97-122, 142-161. 
s Widal. Etude sur l'infection puerperale. These de Paris, 1889. 

4 Mixius. Bakteriologische Untersuchungen eininger Falle puerperaler Sepsis. D. I., Berlin. 
1892. 

6 Goldscheider. Klinische una bakteriol. Mittheilungen uber Sepsis puerperalis. Charite 
Annalen, 1893, xviii. 164-242. 

c Kronig. Bakteriologie des (jenital-kanales der schwangeren, kreisenden und puerperalen 
Frau. Leipzig, 1897. 

7 Bumm. Histologische Untersuchungen uber die puerperale Endometritis. Arch. f. Gyn., 1891, 
xl. 398. 

8 v. Franque. Bakteriologische Untersuchungen bei normalem und fieberhaftem. Wochenbett. 
Zeit. f. Geb. u. Gyn., 1893, xxv. 277. 

9 Bumm. Ueber die Aufgaben weiterer Forschungcn auf dem Gebiete der puerperalen Wundin- 
fektion. Arch. f. Gyn., 1889, xxxiv. 325. 



590 PATHOLOGY OF THE PUERPERIUM. 

which decomposed albumin and produced poisonous substances ; and 
Doederlein, 1 in another case presenting a frothy, purulent secretion, was 
able to isolate an anaerobic gas-producing coccus. Kronig 2 in 43 abnor- 
mal puerperia found organisms which did not grow on the usual media, 
and in 32 of them obtained organisms which only grew anaerobically. 

Beside the organisms which we have mentioned, it is not unlikely that 
further research will show still other organisms which may play a part 
in the production of isolated cases of infection ; but from what we have 
already said, it is perfectly clear that the organisms usually concerned 
are the well-known pyogenic organisms (streptococcus, staphylococcus, 
colon bacillus, and gonococcus) and the various putrefactive organisms. 

Some idea of the frequency with which the different organisms are 
concerned in the production of the puerperal infections may be gained 
by recurring to the work of Kronig, 3 who examined 179 cases of puer- 
peral endometritis bacteriologically, and, as a result of his observations, 
divided them into three groups, namely, pyogenic, gonorrheal, and saprse- 
mic. The pyogenic group comprised 79 cases, in 75 of which the infec- 
tive agent was the streptococcus, and in 4 the staphylococcus. In 50 
cases he was able to demonstrate the presence of the gonococcus, and in 
43 of the 50 sapraemic cases he was able to demonstrate organisms which 
did not grow on the usual culture media, 32 of which were anaerobic. 

The writer has examined the uterine lochia bacteriologically in 150 
cases in which the temperature rose to 101° F. or higher during the 
first ten days of the puerperium, and found 

Streptococci 31 cases. 

Streptococci and colon bacilli 5 " 

Streptococci, staphylococci, and bacilli 2 " 

Streptococci, colon and gas bacilli 2 " 

Streptococci, staphylococci, gas and typhoid bacilli .... 1 case. 

Streptococci, staphylococci, colon and ge.s bacilli . . . 1 " 

Streptococci and unidentified bacilli 2 cases. 

Staphylococci 4 " 

Colon bacilli 11 " 

Gonococci 7 " 

Gonococci and colon bacillus 1 case. 

Unidentified aerobic bacteria 4 cases. 

Unidentified anaerobic bacteria 8 " 

Diphtheria bacillus 1 case. 

Typhoid bacillus 1 " 

Bacteria seen in cover-slips, but which would not grow in any media 45 cases. 

Absolutely sterile 25 " 

Pathological Anatomy. After having thus considered more or less in 
detail the organisms which play a part in the production of puerperal 
infection, we now turn to the consideration of the lesions produced by 
them. 

The lesions may vary very greatly in a given case ; and it is probably 
for this reason that the older authors did not earlier appreciate the true 
nature of the affection. The lesions may vary from a coated perineal 
tear to an inflammatory process involving the entire generative tract, 
and in many cases extending beyond it to the parametrium or peri- 
toneum, and sometimes resulting in a general pyaemic infection. In 

1 Doederlein. Vorlaufige Mittheilung uber weitere bakteriologische Untersucbungen des 
Scheidensekretes. Cent. f. Gyn., 1894, 779. 

- Kronig. Aetiologie und Therapie der puerperalen Endometritis. Cent. f. Gyn., 1895,422-432. 
Discussion uber Endometritis. Verh. d. deutschen Ges. f. Gvn., 1895, 498-502. 

s Kronig. Op. cit. 



PUERPERAL INFECTION. 5M 

other cases the infectious elements pass through the port of entry with 
such rapidity that they do not there give rise to local lesions, but 
produce a septicaemia, which is rapidly fatal. The most fatal forms 
of puerperal septicaemia end with extreme rapidity, and have been well 
designated by the French as " sepsis foudroyante." In most cases of 
puerperal infection, however, the endometrium is the portion affected, 
and in the majority of cases the disease remains limited to it, and is 
designated as septic or putrid endometritis, according as it is the result 
of the invasion of pyogenic or putrefactive organisms. 

In puerperal infection any portion of the generative tract may be the 
seat of the lesion, and in many cases more than one portion is involved, 
and we accordingly have to consider puerperal vaginitis, endometritis, 
metritis, parametritis, metro-lymphangitis, metro-phlebitis, salpingitis, 
oophoritis, peritonitis, pyaemia, and phlegmasia alba dolens. 

Puerperal Ulcer. We shall now take up the consideration of 
the various lesions more in detail, and first turn our attention to those 
occurring about the vulva and vagina. In the pre-antiseptic period the 
puerperal ulcer was of very frequent occurrence ; but with the intro- 
duction of aseptic methods into midwifery its frequency has become 
markedly diminished, so that now it occurs but rarely. 

These ulcers appear on the surface of the tears about the vulva and 
perineum, and soon take on a dirty, greenish-yellow appearance, which 
is due to necrosis, and are bathed by a dirty purulent secretion. 

In some cases the ulcers take on a markedly diphtheritic appearance, 
and were formerly designated as " diphtheritic ulcers"; but careful his- 
tological examination has shown that they have nothing in common with 
diphtheria except their external appearance. 

As a rule, the puerperal ulcers about the vulva give rise to very little 
systemic disturbance, and would frequently pass unnoticed were it not 
for ocular inspection. 

Puerperal Vaginitis may occur in two forms : either as a diffuse, 
general inflammation, when the mucosa becomes thickened, soft, and 
reddened, and bathed with an abundant purulent secretion. While in 
other cases, and especially when torn surfaces are present, a larger or 
smaller portion of the vagina may be covered by a pseudo-diphtheritic 
membrane. This membrane may vary in extent from a small patch 
covering a slight tear to a complete cast of the entire vaginal canal. 

Until recently it was believed that none of the so-called cases of 
diphtheria of the vagina were due to the invasion of the bacillus diph- 
theriae. But the recent observations of Bumm, 1 Nisot, 2 and the writer 3 
show that in rare instances we may have to deal with true diphtheria 
of the vagina caused by the Loeffler bacillus. 

Endometritis. The most usual lesion in puerperal infection is an 
inflammation of the lining membrane of the uterus. When we recall 
the condition of the uterus immediately post partum, with its bleeding 
surfaces, its large amount of recently torn tissue, and the large gaping 
thrombosed placental sinuses, we readily see how organisms which have 

i Bumm. Ueber Diphtherie und Kindbettfieber. Zeit. f. Geb. u. Gyn., 18S5, xxxiii. 126-136. 

2 Nisot. Diphtherie vagino-uterine puerperale. Serotherapie guerison. Annales de Gyn., 1896, 
xlv. 259. 

3 Williams. Diphtheria of the Vulva. Amer. Journ. Obstet., 1898, xxxviii. 180-185. 



592 



PATHOLOGY OF THE PUERPERJUM. 



been introduced into the uterus during labor easily find entry into its 
tissues. And when we consider the mechanism by which the decidua is 
normally removed, we readily see that an ideal culture-medium is pre- 
pared by nature for the reception and propagation of organisms intro- 
duced from without. 

In puerperal endometritis the infection may be limited to the placental 
site, or may extend over the entire mucosa. When the placental site 
alone is infected, we usually find the organisms growing into the thrombi 
and producing comparatively little local reaction. But when the entire 
internal surface of the uterus is affected, the endometrium becomes 
converted into a stinking, sloughing surface, made up of necrotic mate- 



W 




Uterus from patient dying on tenth day from a mixed infection— streptococcus and colon bacilli. 



rial and decidual debris, and bathed with a bloody, purulent discharge. 
The necrotic material soon takes on a dirty, yellowish-green appearance, 
and in many instances we find ulcerated surfaces coated with fibrin and 
presenting the clinical picture of diphtheria. This form of endometritis 
was formerly designated as diphtheritic, but, as stated when considering 
the vagina, we have to deal not with a true diphtheria, but simply with 
a fibrinous exudation, the result of an intense necrosis following the 
invasion of the usual pyogenic organisms. 

When the infection is due to the streptococcus or staphylococcus, there 
is usually very little odor accompanying it, but when it is due to inva- 
sion by the colon bacillus or any of the various putrefactive organisms, 
we find the interior of the uterus bathed with a profuse foul-smelling 



PUERPERAL INFECTION. 



593 



discharge which frequently contains gas bubbles. The amount of ne- 
crotic material produced in puerperal endometritis is often very great, 
and, after curetting, it may recur with great rapidity. Fig. 357 rep- 
resents the uterus from a case of puerperal infection due to the strepto- 
coccus and colon bacillus, in which the woman succumbed ten days 
after the birth of the child, having been curetted three or four days 
before death, when it was said the uterus was scraped perfectly clean. A 
glance at the drawing, however, shows the entire uterine cavity filled with 
necrotic material, which in all probability was produced in the interval 
elapsing between the curettage and the time of death. 

In most cases the infection remains limited to the endometrium, but 
in many others it progresses beyond it, giving rise to a metritis, a lym- 
phangitis, or a phlebitis, as the case may be. The extension of the pro- 
cess beyond the endometrium usually occurs through the lymphatics, and 
we may trace in their course areas of inflammation extending from the 
endometrium to the peritoneal surface of the uterus. In other cases, and 
especially where the infection has been limited to the placental site, we 



Fig. 358. 




Uterus from patient dying on tenth day from a pure streptococcic infection. 



find that the thrombi have been invaded by the micro-organism, result- 
ing in a phlebitis which may remain limited to the uterine wall, or may 



38 



594 PATHOLOGY OF THE PUEBPERIUM. 

rapidly extend beyond it and give rise to the various thrombotic forms 
of puerperal infection. 

It would appear that the lesions produced in the endometrium vary 
very considerably according to the micro-organisms concerned, and par- 
ticularly according to their virulence. In the cases in which we have 
to deal with a virulent streptococcus or staphylococcus infection, the 
changes produced in the endometrium are comparatively slight, the proc- 
ess rapidly spreading through the lymphatics or veins past the uterus, 
and giving rise to a peritonitis or a general systemic infection. "Whereas, 
in the cases due to the putrefactive organisms, and also those due to the 
colon bacillus and to the ordinary pus-organisms of lesser virulence, the 
process remains more or less limited to the endometrium and gives rise to 
marked local lesions. Fig. 358 represents the uterus from a woman dying 
of a virulent streptococcic infection, and in this it is seen that its interior is 
almost perfectly smooth, and presents nothing which could have been 
removed by means of the curette, and stands in marked contrast to the 
case figured above, in which the infectious agents were the streptococcus 
and colon bacillus. 

When we consider the histology of puerperal endometritis we find 
that these differences are still further accentuated. Most of our knowl- 
edge on this point we owe to the researches of Bumm l and Doederlein, 2 
both of whom have shown that there is a marked histological differ- 
ence between putrid and septic endometritis. According to Bumm, 
in sections through the wall of a uterus the seat of a putrid 
endometritis we find a thick layer of necrotic material lining the 
uterine cavity, and imbedded in it large numbers of the offending 
micro-organisms. Beneath this we find a thick layer of small-cell 
infiltration, which we may designate as the zone of reaction, and beneath 
it more or less normal tissue. Careful study of the sections shows us 
that the micro organisms are limited almost entirely to the superficial 
necrotic layer; a few may be found in the reaction zone, but none in the 
tissues beneath it, thus showing nature's mode of preventing the invasion 
of the body by the micro-organisms. (See Plates XXXIY. and XXXY.) 

These pictures are observed not only in the cases due to infection with 
the putrefactive organisms, but also in those cases in which the pyogenic 
organisms possess only a slight degree of virulence. On the other hand, 
in cases of septic endometritis, and especially where the organisms are 
virulent, we observe a totally different appearance. Here we likewise 
find adjoining the uterine cavity a layer of necrotic material, which, how- 
ever, is usually thinner than in the preceding case. In this we find 
micro-organisms. The zone of small-cell infiltration is either lacking or 
very imperfectly developed, and we observe the micro-organisms making 
their way down through the decidua, and along the lymphatics through 
the muscular wall of the uterus out to its peritoneal surface. The writer 
has been able abundantly to confirm the observations of Bumm, and 
there is no doubt that his conclusions are amply justified. 

The effect produced by various micro-organisms was strikingly illus- 
trated in one of the writer' s cases, in which he had to deal with a double in- 

i Bumm. Histologische Untersuchungen uber die puerperale Endometritis. Arch. f. Gyn., 1891, 
xi. 398. 

2 Doederlein. Die Beziehungen der Endometritis zu den Fortpflanzungs vorgangen. Verh. d. 
deutschen Ges. f. Gyn., 1895, 224-242. 





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PLATE XXXV. 



FIG. 1. 






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Section through Deeidua from Putrid Endometritis, removed by Curette on 

Ninth Day. (Bumm.) 

a. Necrotic tissue swarming with bacteria, b. Zone of reaction, showing nuclei of leucocytes. 

FIG. 2. 






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Section through Deeidua. Septic Endometritis, Curetting 

on Seventh Day. (Bumm.) 

a. Necrotic tissue, bacteria in masses, b. Resisting-zone of leucocytes, c. Lumen of glands. 

d. Cross-section of bloodvessels, e. Remnants of epithelial cells of uterine glands. 

FIG. 3. 



:.>.,--...^o;; : j 



Streptococci growing between Muscle-fibres. (Bumm.) 



PUERPERAL IXFECTION. 595 

fection with the streptococcus and colon bacillus. On making sections 
through the uterine wall in this case we observed the characteristic ne- 
crotic zone lining the cavity of the uterus, and in it both forms of micro- 
organisms. Beneath this, the zone of small-cell infiltration was fairly 
well developed, and in its upper part we were likewise able to find both 
forms of organisms. But in its lower portion we found only the strep- 
tococci, which continued their way through the uterus by means of the 
lymphatics, and on reaching the peripheral surface gave rise to a perito- 
nitis. It would, therefore, appear that nature endeavors to confine the 
micro-organisms to the interior of the uterus by interposing between the 
necrotic layer and the deeper portions a wall of small-cell infiltration, 
which acts as an efficient filter when the micro-organisms are not viru- 
lent, but which fails to restrain them when they possess a marked degree 
of virulency. 

Parametritis. One of the most frequent complications of the uterine 
infection is parametritis, which is usually due to the propagation of the 
micro-organisms from the uterus to the peri-uterine connective tissue 
by means of the lymphatics. The first effect of their invasion is a 
marked inflammatory oedema, but very little or no suppuration. In 
mild cases the infection goes only thus far, while in more severe cases 
it rapidly spreads to the surrounding connective tissue and eventuates 
in abscess-formation. The infectious agents in severe cases follow 
the course of the lymphatics, either behind the peritoneum, when they 
may give rise to retroperitoneal phlegmons, which in rare cases may 
extend up as high as the posterior mediastinum, while in other cases 
they follow the lymphatics, which extend into the anterior portion of 
the pelvis, when we have inflammatory phenomena occurring about the 
inguinal canal, and in some cases following the connective tissue sur- 
rounding the greater vessels of the thigh, when it gives rise to phleg- 
masia alba dolens. 

Occasionally the parametritic involvement has its origin from infected 
tears about the cervix, but in the vast majority of cases it is due to infec- 
tion from the uterine cavity. 

As has already been pointed out, in a considerable number of cases 
the endometritic process extends into the uterine wall, and there gives 
rise to the various lesions of metritis, which may vary from small areas 
of small-cell infiltration to marked abscess-formation. In the majority 
of cases, however, in which we meet with abscesses scattered through 
the uterine wall, we find that they are due to lymphatic involve- 
ment, and, as the lymphatic supply of the uterus is most marked just 
beneath the peritoneum, we find the abscesses most frequently in that 
situation. 

Salpingitis. In a certain proportion of cases the process extends 
directly from the uterine cavity to the Fallopian tubes, and there gives 
rise to various inflammatory phenomena. In a small proportion of 
cases, however, the salpingitis is due to infection through the lymphatics, 
and not by continuity from the uterine cavity. In a certain number of 
cases we observe an oophoritis ; here the ovaries are enlarged to several 
times their usua'l size, and are very oedematous. The process may stop 
here or go on to abscess-formation, when we have to deal with a typical 
ovarian abscess. The ovarian infection in the vast majority of cases is 



596 PATHOLOGY OF THE PUERPERIUM. 

due to lymphatic involvement, and is usually coincident with affections 
of the parametrium. In a small number of cases, however, the ovarian 
infection may be due to direct infection of a ruptured follicle by means 
of the peritonitic fluid. 

Peritonitis. In the vast majority of cases the fatal termination in 
puerperal infection is due to peritonitis. As we pointed out when con- 
sidering the histological changes in puerperal endometritis, the strepto- 
cocci or other infecting agents rapidly make their way from the interior 
of the uterus to its peritoneal surface by means of the lymphatics, and 
there give rise to peritonitis. This is the usual mode of infection; but 
in certain other cases, which, however, occur but rarely, the peritoneum 
is infected by pus which escapes from the Fallopian tubes, and in other 
cases by the rupture of parametritic or ovarian abscesses. But in none 
of the autopsies which the writer has performed upon women dead of 
puerperal fever has he observed a peritonitis which he could attribute 
to direct transmission through the tubes. 

Pyemia. The pysemic form of puerperal infection usually results 
from the infection of thrombi at the placental site and the subsequent 
inflammatory changes occurring in the veins. The thrombosis may be 
limited to a comparatively small area and be entirely within the uterine 
wall, or it may extend beyond the uterus, and we occasionally find all 
the pelvic vessels thrombosed up as high as the junction of the renal 
veins with the inferior vena cava. By the breaking down of the thrombi 
small particles escape into the circulation and are carried by the blood- 
current to various portions of the body, where they give rise to meta- 
static abscesses, from which apparently no portion of the body is exempt. 
In this form of puerperal infection we may find metastatic abscesses in 
all the internal organs, and frequently we find the synovial surfaces 
affected, giving rise to swellings about the joints, which, if not promptly 
treated, lead to their complete destruction. 

In a number of other cases we notice blebs or bulla? appearing on 
various portions of the body, which are due to the same cause, and in 
whose contents we may readily demonstrate the offending micro-organ- 
ism. In most cases of pyaemia we find very little uterine involvement, 
and when death occurs it is due to the general exhaustion following a 
prolonged suppurative process, rather than to peritonitis, which is the 
usual cause of death in the other forms of infection. 

Phlegmasia Alba Dolens. As we pointed out when considering 
the question of parametritis, this affection is frequently due to the exten- 
sion through the lymphatics of the parametritic process to the tissues 
surrounding the great vessels of the thigh. Usually, however, it results 
from the extension of thrombosis of the pelvic veins. But in not a few 
cases it appears to be the only manifestation of the infectious process, 
and under such circumstances its mode of production is very difficult 
of explanation. 

Etiology. From the consideration of the various bacteria concerned in 
puerperal infection, it is evident that we have to deal with those organisms 
with which we are familiar as causing wound-infection ; and, generally 
speaking, we may say that puerperal infection is wound-infection, caused 
by the introduction of pathogenic organisms within the generative tract, 
either during or immediately after labor. In other words, we have to 



PUERPERAL INFECTION. 597 

deal with a direct infection from without, the infectious germs being 
brought to the woman by the hands, instruments, or any object which 
comes in contact with her generative organs. 

Puerperal infection is contact-infection, and this conception was first 
definitely enunciated by Semmelweiss 1 in 1847, in the following words: 
" I consider puerperal fever, not a single case excepted, as a resorption 
fever, caused by the resorption of a decomposed organic-animal material. 
The first result of the absorption is a change in the blood, and the exu- 
dations are the result of this change. The decomposed animal-organic 
material, which when resorbed causes childbed fever, is brought to the 
individual from without in the greatest majority of cases, and this is 
infection from without. These are the cases which represent the epi- 
demics of child-bed fever; these are the cases which can be prevented." 

In the latter part of the last century puerperal fever began to be con- 
sidered as a contagious malady in England. This conception apparently 
originated with Thomas Kirkland, 2 of Ashby, in 1774, but was first 
clearly enunciated in 1795 by Gordon, of Aberdeen, in his treatise 
" On the Epidemic of Puerperal Fever, as it prevailed in Aberdeen 
from December, 1789, to March, 1792," in which he gave a table of 
77 cases which he had attended himself. 

In this country the man who played the greatest part in introducing 
the conception of the contagious or infectious nature of the affection was 
Oliver Wendell Holmes, 3 who in 1843 wrote an article on " Puerperal 
Fever as a Private Pestilence," in which he clearly showed that it was 
a preventable affection, and owed its origin either to the accoucheur or 
midwife. Holmes's teachings, however, did not exert the influence which 
might have been expected from them; for they were opposed by the lead- 
ing obstetricians of the country, notably Meigs and Hodge, 4 of Phila- 
delphia, Meigs stating that he preferred to consider puerperal fever as 
due to the workings of Providence, which he could understand, rather 
than to an unknown infection of which he could form no conception. 

For many years the main theory in Europe as to the causation of puer- 
peral fever was that it was due to miasmatic or atmospheric influence. 
And this view continued until after the appearance of Semruelweiss's 
article in 1861, although in 1864 Hirsch, 5 after studying the matter from 
an historical stand-point, came to the conclusion that it was of infectious 
rather than of miasmatic origin. 

It was not, however, until Lister had introduced antiseptic methods 
into surgery, and Stadtfelt, of Copenhagen, had recommended the use 
of bichloride of mercury in obstetrics, that the great mass of the pro- 
fession began to understand that puerperal fever was due to contact- 
infection, and could be prevented to a very great degree. After the 
bacteriological work of Pasteur 3 and his successors, and the constant 
finding of streptococci in fatal cases, the question was raised above all 
doubt, and at the present time no one doubts the infectious nature of the 
disease. 

1 Semmelweiss. Die Aetiologie der Begriff u. die Prophylaxis des Kindbettfiebers Pest. Wien u. 
Leipzig, 1861. 

2 Kirkland. Treatise on Childbed Fever, 1774. 

3 Holmes. Puerperal Fever as a Private Pestilence. Boston, 1865. 
* Meigs. On Childbed Fever. Phila., 1854. 

5 Hirsch. Historisch-pathologische Untersuchungen iiber Puerperalfieber. Erlangen, 1864. 

6 Pasteur. Septicemie puerperale. Bull, de 1' Acad, de Med.. 1879, 260, 271. 



598 PATHOLOGY OF THE PUERPERIUM. 

Modes of External Infection. The most usual mode of infec- 
tion is by the hands of the obstetrician or the midwife, and no one who 
has observed the way in which the average medical man conducts a labor 
case can wonder that puerperal fever occasionally occurs. The introduc- 
tion of dirty instruments, as well as dirty hands, plays an important 
part in the "production of the infection. A source of infection which 
is frequently overlooked is copulation during the latter weeks of preg- 
nancy ; and not infrequently, especially among the lower classes, the woman 
infects herself by fingering her genitalia, or even by making internal ex- 
aminations. Contact with secretions from wounds of any kind also plays 
an important part in its production, and whether the purulent secretion 
be from an external wound or anywhere within the body, the results will 
be the same. It is only necessary to recall in this connection the case 
of Dr. Rutter, of Philadelphia, who was followed wherever he went by 
an epidemic of puerperal fever, while his brother practitioners were prac- 
tically free from it. It appeared later that the source of infection in his 
cases was an ozaena, from which he was constantly infecting his hands. 

The disease is often due to wounds on the hands of the nurse, and 
many cases may be traced to bone-felons and other affections of the 
fingers, aud not infreqently to a pustulous eczema on the hands. 

For many years it has been known that physicians attending cases of 
erysipelas, and then going to women in labor, frequently had to deal 
with puerperal infection, and one of the old ideas concerning the disease 
was that it was identical with erysipelas, and it was not until bacteriology 
showed us that both erysipelas and most cases of puerperal infection are 
due to the streptococcus that this relation was understood. At the present 
time the majority of observers believe that there is no essential difference 
between the streptococcus erysipelatis of Fehleisen and the ordinary 
streptococcus pyogenes. It has frequently been observed that puerperal 
fever also occurs in the practice of those attending diphtheria and scarlet 
fever and occasionally typhoid cases. There is no essential relationship 
between these affections, but we know that in both diphtheria and scarlet 
fever we frequently meet with complications which are due to the strep- 
tococcus, and these streptococci are conveyed to the woman in labor. 

It is generally stated that air infection plays an important part in the 
production of puerperal infection, and many advise covering the external 
generative organs with an occlusive pad, to prevent the entry of air 
within the vagina, and thus avoid this source of infection. It appears 
to us, however, that air-infection is a very infrequent cause of the disease, 
if it ever occurs, and we cannot indorse the statements of Garrigues, 1 in 
his article on this subject in the American Text-book of Obstetrics, in 
which he attributed an epidemic of puerperal fever in the New York 
Lying-in Hospital to the presence of a dead rat in the cellar. It is 
much more probable that the epidemic was due to imperfect hand-disin- 
fection on the part of his assistants, or to the introduction of pathogenic 
organisms within the vagina by the hands of the patients themselves. 
In England, and to a slight extent in this country, sewer-gas is believed 
to play a prominent part in the production of puerperal infection, and 
at a meeting of the health officers of Great Britain in London, some years 
ago, at which the writer was present, a prominent medical man stated that 

1 Garrigues. Puerperal Infection. American Text-book of Obstetrics, 1S95, 683-734. 



PUERPERAL INFECTION. 599 

the first duty of the obstetrician on visiting the house of his patient was 
to inspect the sanitary arrangements instead of examining the patient. 
And the writer was informed by good authority that after the serious 
illness of a prominent woman from puerperal infection, in one of the 
smaller towns of England, the entire sewerage system of the town was 
torn up to discover the leak from which the sewer-gas escaped, which was 
supposed to have been the cause of the disease. There can be no doubt 
that the danger of infection from the air or from sewer-gas is greatly 
exaggerated, and it will be spoken of less and less frequently as medical 
men become better versed in the technique of rigorous hand-disinfection. 

To show what an accurate conception Semmelweiss 1 had of the various 
modes of contact-infection, it may be interesting to quote what he says in 
this connection : " The bearer of the decomposed animal-organic material 
is the examining-finger, the operating-hand, instruments, bedclothes, the 
atmospheric air, sponges, the hands of the midwife or nurses which come 
in contact with the excrement of women sick with puerperal fever, and 
after that handle pregnant and parturient women. In other words, the 
bearer of the decomposed animal-organic material is anything which is 
soiled by a decomposed animal-organic material and comes in contact 
with the genitals of these patients/' 

Auto-infectiox. Every one at the present time believes that the 
vast majority of cases of infection are the result of the introduction 
from without of pathogenic micro-organisms into the genital canal of 
the pregnant or parturient woman by means of the examining-finger or 
in some other way. But many also believe that in a certain number of 
cases the infection is not due to the introduction of organisms from 
without, but owes its origin to micro-organisms which were already 
within the woman before the onset of labor. To infections arising in 
this way the term " auto-infection " is applied. The term originated 
with Semmehveiss, 2 who stated : " In rare cases the decomposed animal 
material, which causes childbed fever when absorbed, is produced within 
the patient herself. These are the cases of auto-infection, and cannot 
be prevented." 

With the enthusiasm which attended the introduction of antiseptic 
methods into midwifery, the conception of auto-infection was lost sight 
of for a time, and it was only when the statistics of well-conducted lying- 
in establishments showed that a certain amount of infection occurred in 
spite of the rigorous application of antiseptic principles that the idea of 
auto -infection was rehabilitated by Ahlfeld 3 and Kaltenbach. 4 Of course, 
with the recognition of the fact that puerperal fever is due to certain 
micro-organisms, the definition introduced by Semmelweiss 5 fell to the 
ground, as it is not possible for the organisms to originate spontaneously 
within the body of the woman. The conception was then introduced 
by Kaltenbach 6 that in a considerable number of cases pathogenic organ- 

1 Semmelweiss. Die Aetiologie der Begriff u. die Prophylaxis des Kindbettfiebers Pest. Wein u. 
Leipzig, 1861. 

2 Semmehveiss. Op. cit. 

3 Ahlfeld. Beitriige zur Lehre von Resorptionsfieber im Wochenbett und von der Selbstinfektion. 
Berichte und Arbeiten, 1883, i. 1G5. Beitrag zur Lehre der Selbstinfektion. Cent. f. Gyn., 1887, 
729. 

4 Kaltenbach. Zur Antisepsis in der Gcburtshulfe. Volkmann's Sammlung klin. Vortrage, Nr. 
29o. Ueber Selbstinfektion. Verh. deutschen Ges. f. Gyn., Freiburg, 18S9. 

5 Semmelweiss. Op. eit. 

6 Kaltenbach. Ueber Selbstinfektion. Verh. deutschen. Ges. f. Gyn., Freiburg, 1SS9. 



600 PATHOLOGY OF THE PUERPERIUM. 

isms are normally found in the vaginae of pregnant women, which may be 
introduced into the uterus by the introduction of a perfectly sterile finger 
within the vagina. It is apparent in such cases that we do not have to 
deal with auto-infection in the strict sense of the word, and much con- 
fusion would have been avoided had the term indirect infection been 
substituted for it; because the micro-orgauisms must have been intro- 
duced into the vagiua at some period of life, and the question simply 
resolves itself into one of time. Certain observers, notably Slavjansky 1 
and Szabo, 2 state that auto-infection, even in this modified sense, is not 
possible, and that all cases of puerperal infection are due to the intro- 
duction of pathogenic micro-organisms at the time of labor. 

This appears to be an extreme view, and the question must stand or 
fall with the results of the bacteriological examination of the generative 
tract in the pregnant and non-pregnant conditions. If careful investi- 
gation shows that pathogenic micro-organisms are absent from the uterus 
and vagina of pregnant women, we must abandon all idea of auto-infec- 
tion. If, on the other hand, they can be demonstrated in apparently 
healthy women during pregnancy, we shall be forced to admit its possi- 
bility, no matter what our previous ideas may have been, and to be- 
lieve that all cases of puerperal fever are not due to infection from 
without. 

Practically all bacteriological investigators are united in claiming that 
the body of the normal uterus is free from micro-organisms, both in the 
pregnant and the non-pregnant condition. This fact has been amply 
demonstrated by the work of Goenner, 3 Doederlein/ Winter, 5 Ott, 6 
Czerniewski, 7 Stroganoff, 8 Kronig and Menge, 9 and Doederlein and Win- 
ternitz, 10 while Strauss and Sanchez-Toledo 11 have demonstrated the same 
in the lower animals. The only investigators who contend that bacteria 
can be found in the non-infected uterus are Franz 12 and Burckhardt, 13 
who state that they can be demonstrated in its cavity in the latter part 
of the puerperium in a large proportion of cases. Their results, how- 
ever, are controverted by the recent work of Doederlein and Winter- 
nitz, 14 and appear invalidated by the fact that the writer found the 
uterine lochia absolutely sterile in 26 out of 150 women who presented 
rises of temperature in the puerperium (p. 590). 

1 Slavjansky. Die Antiseptik in der Geburtskiilfe. Verh. de x. internat. med. Congresses, 1891, 
iii. Abth. vii. 1. 

2 v. Szabo. Zur Frage der Selbstinfektion. Arch. f. Gyn., 1889, xxxvi. 77-101. 

3 Goenner. Ueber Mikroorganisrnen in Sekrete der weibliehen Genitalien wahrend der Schwan- 
gerschaft und bei puerperalen Erkrankungen. Centralbl. f. Gyn., 1887, 444. 

4 Doederlein. Untersuchunguber das Vorkomen von Spaltpilzen in den Lockien des Uterus und 
der Vagina gesunder und kranker Woeknerrinnen. Arek. f. Gyn., 1887, xxxi.. 412. 

5 Winter. Die Mikroorganismen im Genitalkanal der gesunden Fraun. Zeitsckr. f. Geb. u. Gyn., 
1888, xiv. 443. 

6 Ott. Zur Bacteriologie der Lockien. Arck. f. Gyn., 1888, xxxii. 436. 

7 Czerniewski. Zur Frage von den puerperalen Erkrankungen. Eine bakteriologiscke Studie. 
Arck. f. Gyn.. 1888, xxxiii. 73. 

8 Strogahoff. Bakteriologiscke Untersuckungen des weiblieben Genitalscklauckes. Centralbl. 
f. Gyn., 1897, 935. Bakteriologiscke Untersuckunsren des Genitalkanales beim Weibe in verschei- 
denen Perioden ikres Lebens. Monatssckr. f. Geb. u. Gyn., 1895, ii. 365-399, 494-504. 

9 Kronig. Scheidensekret-untersuckungen bei 100 Sckwangeren. Aseptik in der Geburtskiilfe. 
Centrabl, f. Gyn., 1894. 3-10. 

10 Doederlein and Winternitz. Die Bakteriologie der puerperalen Sekrete. Hesrar s Beitrage zur 
Geb. u. Gyn., iii. 161-174, 1900. 

11 Strauss and Sanchez-Toledo. Septicemie puerperale experimentale. Xouv. Arch, d'obstet. et 
degyn., 1889, cv. 277-95. 

12 Franz. Bakteriol. und. kliniscke Untersuchunsren iiber leickte Fiebersteigerungen in Wochen- 
bette. Hesrar's Beitrage zur Geh. u. Gyn., iii. 51-100, 190». 

13 Burckhardt. Ueber den Keimgekalt der Uteruskohle bei normalen Woeknerrinnen. Centralbl. 
f. Gyn., 1898, ' 

""Ibid. 



PUERPERAL INFECTION. 601 

When we come to consider the bacterial contents of the cervix in the 
healthy woman, we find that the conclusions are not so uniform. Thus, 
Winter, 1 Doederlein, 2 and other observers state that micro-organisms 
are present in the cervical canal in most cases : while, on the other hand, 
StroganofF 3 , and Goebel 4 state that they are usually absent. Goenner 6 
and Walthard 6 believe that it is normally sterile in all cases. 

The contradictory results of the various observers were apparently 
satisfactorily reconciled by Walthard's 7 work. He found that cultures 
taken from the lower portion of the cervical canal contained identically 
the same micro-organisms as the vagina, but that they became less plenti- 
ful as the internal os was approached, disappearing altogether about one- 
third of the way up. It would therefore appear that the observers who 
found bacteria in the cervix obtained the secretion from the lower por- 
tion of its canal ; while those who reported negative results obtained the 
secretion from higher up. Accordingly, we may conclude that both the 
uterus and the upper portion of the cervix are practically, if not abso- 
lutely, sterile ; and can therefore offer no possibility for the occurrence 
of auto- or indirect infection. 

The question accordingly resolves itself into the demonstration of the 
presence or absence of pathogenic micro-organisms in the healthy vagina, 
and, accordingly as this can be done, the doctrine of auto-infection must 
be generally accepted or absolutely abandoned. Ahlfeld, 8 in all his 
articles upon the subject, states that " the vagina is swarming with vari- 
ous varieties of pathogenic organisms, and auto-infection can only be 
prevented by thoroughly disinfecting the vagina in every case by anti- 
septic douches." 

Unfortunately, the bacteriological investigations as to the bacterial 
contents of the vaginal secretion of pregnant women have not led to 
absolutely satisfactory and conclusive results. On the one hand, the 
work of Goenner, 9 Thomen, 10 Samschin, 11 Kronig and Menge, 12 Bensis, 13 " 
and the writer 14 in 1898, appear to show that pathogenic micro-organ- 
isms, with the exception of the gonococcus. cannot be found in the vagina 
of pregnant women ; while, on the other hand, numerous investigators 
have demonstrated the presence of streptococcus in a varying proportion 
of their cases, as shown by the following table : 

1 Ibid. 

2 Ibid. 

3 Ibid. 

4 Gobel. Der Bakteriengehalt der Cervix. Centralbl. f. Gvn., 1896, 84. 
s Ibid. 

6 Walthard. Bakteriologische Untersuchungen des weiblichen Genitalsekretes in der Gravi- 
dity und in Puerperium. Arch. f. Gyn., 1895, xlviii. 201-269. 

* Ibid. 

8 Ahlfeld. Beitrage zur Lehre von Resorptionsfieber im Wochenbett und von der Selbstinfek- 
tion. Berichte und Arbeiten, 1883, i. 165. Beitrag zur Lehre der Selbstinfektion. Centralbl. f. 
Gyn., 1887, 729. Beitrage zur Lehre vom'Resorptionsfieber in der Geburt und im Wochenbette und 
von der Selbstinfektion. Zeitschr. f. Geb. u. Gyn., 1893, xxvii. 466-519. 

a Ibid. 

10 Thomen. Bakteriologische Untersuchungen normaler Lochien und der Vagina und Cervix 
Schwangerer. Arch. f. Gyn., 1889, xxxvi. 231. 

11 Samschin Ueber das Vorkomen von Eiterstaphylococcen in den Genitalien von gesunder 
Frauen. Deutsche med. Wochen., 1890, 232. 

12 ibid. 

13 Bensis. Recherches sur la fiore vulvaire et vaginal chez la femme enceinte. These de Paris, 
1900. 

14 Williams. The Bacteria of the Vagina and their Practical Significance, based upon the Bac- 
teriological Examination of the Vaginal Secretion of Ninety-two Pregnant Women. Amer. Jour. 
Obstet., 1898, xxxviii. 449-483. 



602 PATHOLOGY OF THE PUEEPERIUM. 

Per cent. Per cent. 

Burckhardt 1 * Witte * 12.5 

Steffeck 2 4 Kottmann 8 13 

Doederlein 3 4.1 Winter 9 15 

Burguburu* 8.5 Williams 10 (1893) .... 20 

Koblancks 9.5 Vahle u 25 

Vahle . . . . . .10 Walthard 12 27 

Thus, it seems, on the one hand, that bacteriological work appears to 
prove that auto-infection is absolutely impossible ; while, on the other 
hand, it indicates that it may occur in a varying percentage of cases. 

The appearance of Doederlein' s 13 work on the vaginal secretion, in 
1892, appeared to reconcile for a time the conflicting results which were 
based upon the bacteriological work which had been clone up to that date. 
He pointed out that the vaginal secretion might occur in one or two 
forms, which he designated as normal and pathological. The normal 
secretion, according to him, w T as a thick, dry, cheese-like material, of a 
whitish color and distinctly acid reaction. Microscopically it contained 
epithelial cells, a pure culture of tolerably long bacilli, and now and then 
a few yeast fungi. It did not contain pathogenic micro-organisms, and 
offered absolutely no support for the doctrine of auto-infection. On the 
other hand, the pathological secretion was fluid, generally of a yellowish 
color suggesting pus, and occasionally contained gas-bubbles. In it 
were found large numbers of leucocytes, many micro-organisms of vari- 
ous kinds, and in a few cases streptococci. Its reaction was less acid 
than in the normal secretion, was occasionally neutral, and in a few 
cases even alkaline. Doederlein's work was based upon the examination 
of 190 pregnant women, 55.3 per cent, of whom presented normal, and 
44.6 per cent, pathological secretion. And in 10 per cent, of the latter 
he was able to demonstrate the presence of streptococci by cultural 
methods. His investigations, accordingly, indicated that auto-infection 
could not possibly occur in women with normal secretion, whereas 
abundant theoretical facilities were present for it in 10 per cent, of the 
pathological cases. 

He supposed that the contradictory results of the investigators who 
had worked upon the subject up to that time could be reconciled by sup- 
posing that those obtaining negative results had worked with the normal, 
and those obtaining positive results with the pathological secretion. 

Kronig, 14 in 1897, stated that he had examined the vaginal secretion 
of 167 pregnant women, and that in none of them was he able to demon- 
strate typical streptococci or any other pathological micro-organisms, 
with the exception of the gonococcus. He therefore concluded that the 

1 Burckhardt. Ueber den Einfluss der Scheidenbakterien auf dem Verlauf des Wocbenbettes. 
Arch. f. Gyn., 189?,, xiv. 71-94. 

2 Steffeck. Bakteriologische Begriindung der Selbstinfektion. Zeitscbr. f. Geb. u. Gyn., 1890, 
xx. 339. 

3 Doederlein. Das Scheidensekret. und seine Beudeutung fur das Puerperalfieber. Leipzig, 
1892. 

4 Burguburu. Zur Bakteriologie des Vaginalesekretes Schwangeren. Arcb. f. exper. Path, und 
Pharmak., Nov., 1892, xxx. 

5 Koblanck. Zur puerperalen Infection. Zeitschr. f. Geb. u. Gyn., 1899, xi. 85-92. 

6 Vahle. Ueber das Vorkomen von Streptococcen in der Scheide GaMrender. Zeitschr. f. Geb. 
u. Gyn., 1896. xxxv. 192-215. 

7 Witte. Bakteriologische Untersuchungschefunde bei path. Zustande imweibl. Genitalapparat. 
mit besonrlerer Beziichsichtigung d^r Eiterreger. Zeitschr f. Geb. u. Gvn., 1892, xxv. i. 

8 Kottmann. Beitragzur Bakteriologie der Vagina. Arch. f. Gvn., 1898, lv. 615. 9 Ibid. 

10 Williams. Puerperal Infection, considered from a Bacteriological Point of View, with Special 
Pveference to the Question of Auto-infection. Amer. Journ. Med. Sci., July, 1893. 

11 D>id. 12 ibid. is ibid. 

14 Kronig. Bakteriologie des Genitalkanales der schwangeren, kreissenden u. puerperalen 
Frau. Leipzig, 1897. 



PUERPERAL INFECTION. 603 

vaginal secretion should be considered as aseptic, and believed that it 
did not offer the slightest evidence in support of the doctrine of auto- 
infection. He stated that in all probability the conflicting results of 
the various observers were due to the different methods by which they 
obtained the secretion for examination ; and whenever it was obtained by 
means of a speculum that it was probable that pathogenic micro-organ- 
isms had been carried up along with it from the vulva ; and he therefore 
recommended that it be obtained by means of a small tube, which could 
be introduced into the vagina under the guidance of the eye, without 
coming- in contact with the labia minora or the margins of the hvmen. 

In 1898, the writer 1 reported to the American Gynecological Society 
the results which he had obtained from the examination of the vaginal 
secretion of 92 pregnant women, from whom he had obtained the secre- 
tion by means of a small tube similar to that employed by Kronig and 
Menge. In none of these cases did he find the streptococcus or staphy- 
lococcus aureus, but in 6 cases he demonstrated the staphylococcus 
epidermidus albus. Whether the latter really existed in the vagina, or 
were due to contamination, is open to doubt ; but as these organisms 
are never found in severe cases of puerperal infection, their presence in 
the vaginal secretion is a matter of indifference as far as the question of 
auto-infection is concerned. He accordingly stated that he could con- 
firm Kronig's 2 observations as to the absence of pyogenic cocci from the 
vaginal secretion of pregnant women, and believed that auto-infection 
due to them could not occur, although he was not prepared to state that 
it might not occasionally occur from other bacteria, especially in some 
of the cases of putrefactive endometritis. 

These conclusions were absolutely contradictory of those to which the 
writer 3 arrived five years previously, when he was able to confirm 
Doederleiir's 4 original work by finding streptococci in 20 per cent, of 
the vaginal secretions which he examined. The only possible explana- 
tion for the different results obtained in the two series of investigations 
must be sought in the manner in which the secretion was obtained for 
examination, as all the other conditions under which the work was 
carried out were identical. In the first series the secretion was obtained 
by means of a sterile glass speculum, and in the second by means of 
Menge's tube ; and it appeared probable, when the speculum was used, 
that a number of bacteria were carried into the vagina by it from the 
margins of the hymen and the inner surface of the labia minora, with 
which it had come in contact ; while such contact was avoided when the 
tube was employed, whereby the secretion was obtained absolutely free 
from contamination. 

This explanation was placed beyond doubt by the examination of 25 
additional cases by the writer, 5 from each of which three sets of cultures 
were made. The first were taken from the hymen and inner surface of 
the labia minora, the second from the vaginal secretion obtained by 
means of Menge's tube, and the third from the vaginal secretion obtained 
by means of a sterilized speculum. Pyogenic cocci or colon bacilli wore 
demonstrated in 80 per cent, of the first series of experiments, in none 
of the second, and in 48 per cent, of the third series, thereby showing 

1 Williams. The Cause of the Conflicting Statements Concerning the Bacterial Contents of the 
Vaginal Secretion of the Pregnant Woman. Amer. Journ. Obstet.. 1898, xxxviii. 807-817. 

2 Ibid. 3 s ee note m, page 602. * Ibid. 6 See note 1. 



604 PATHOLOGY OF THE PUERPERIUM. 

conclusively that the vaginal secretion is absolutely free from pyogenic 
cocci when obtained without contamination ; but that bacteria are pres- 
ent upon the hymen and labia minora in most cases, and that it is im- 
possible to introduce a speculum into the vagina without carrying along 
with it, in at least one-half of the cases, the bacteria which are present 
upon the vulva. 

As a result, therefore, of the work of Kronig and Menge 1 and the 
writer, we consider that it has been fairly satisfactorily demonstrated 
that pyogenic cocci are never present in the vagina of pregnant women,, 
and that therefore there is no possibility of auto-infection as far as those 
organisms are concerned ; and whenever they are demonstrated in the 
uterine secretion of puerperal women they should be regarded as distinct 
evidence of external infection. At the same time it is possible, in rare 
cases, that auto-infection may occur from certain anaerobic organisms 
which are found in the vaginal secretion, but satisfactory evidence can- 
not be adduced in support of such an occurrence until methods have 
been devised which will enable us to isolate and cultivate satisfactorily 
in pure cultures the organisms in question. 

The gonococcus forms an exception in this regard, as it is well known 
that it is the only pyogenic coccus which can live and thrive in the 
vaginal secretion. As we have already indicated, it is not infrequently 
the cause of an elevation of temperature during the puerperium. But 
such cases should not be considered as supporting the doctrine of 
auto-infection, for the reason that women were usually infected either 
before becoming pregnant or in the first few months after its occurrence, 
after which the organisms persist in the crypts of the cervical canal,, 
where they live as parasites, and simply find more suitable conditions 
for development in the first few days of the puerperium, when they 
make their way up into the uterine cavity and manifest their presence 
by the production of fever and an increased discharge. 

An interesting fact in connection with the question of auto-infection 
is that those who believe most in its possibility, and resort to the em- 
ployment of the prophylactic vaginal douches for the destruction of the 
organisms in the vagina, present far less favorable statistics than those 
who take the opposite view. Thus, for example, Ahlfeld, 2 who is the 
most pronounced believer in auto-infection, finds that 38 per cent, of 
his cases present a rise of temperature even after the use of the pro- 
phylactic douche. The results of Kaltenbach, who was a consistent 
believer in auto-infection, and resorted to the routine employment of 
the prophylactic douche, have undergone very material improvement 
since Fehling 3 discontinued its use, after taking charge of the Clinic in 
Halle. And the results of Leopold 4 and Mermann, 5 who do not use 

1 Ibid. 

2 Ahlfeld. Beitrage zur Lehre vom Resorptionsfieber in der Geburt und Wochenbette und von 
der Selbstinfektion. Zeitschr. f. Geb. u. Gvn., 1893, xxvii. 466-519. 

3 Fehling. Ueber die Erkrankungsziffern Entbindungshauser. Deutsche med. Woch., 1896, 426. 
* Leopold. Ueber die Wochenbetten von nicht untersuchten und nicht ausgespulten Gebaren- 

den. Verh. deutsche Ges. f. Gyn., Freiburg, 1889. Dritter Beitrag zur Verhiitung des Kindbett- 
fiebers. Arch. f. Gyn., 1889, xxxv. 149-162. Vergleichende Untersuchungen liber die Entbehrliehkeit 
der Scheidenausspiilungen bei ganz normalen Geburten und iiber die sogenannte Selbstinfektion. 
Arch. f. Gyn., 1894, xlvii. 580-635. Ueber die Entbehrliehkeit der Scheidenausspulungen und 
Auswaschungen bei regelmiissigen Geburten und iiber die grosstmogliche Verwerthung der aus- 
seren Untersuchung in der Geburtshulfe. Arch. f. Gyn.. 1891, xl. 439. 

» Mermann. Zur Antisepsis in der Geburtshulfe. Centralbl. f. Gyn., 1887, 439. Die Entbehr- 
liehkeit und Gefahren innerer Desinfektion normalen Geburten. Verh. deutsche Ges. f. Gyn., Frei- 
burg, 1889. Fiinfter Bericht iiber 200 Geburten ohne innere Desinfektion. Centralbl. f. Gyn., 1893, 
177. Sechster Bericht iiber Geburten ohne innere Desinfektion. Centralbl. f. Gyn., 1894, 786. 



PUERPERAL INFECTION. 605 

the douche at all, show constant improvement, with the increasing pre- 
cision with which objective asepsis is carried out. 

The prophylactic value of the vaginal douche has recently been in- 
vestigated by Kronig 1 and Bretschneideiy and the latter reports 2280 
cases" from the Leipzig Clinic, iu which every alternate case was douched; 
and shows that the puerperium was febrile in 45.18 per cent, of the 
cases in which the douche was used, as compared with 36.78 per cent, of 
the cases in which it was not employed. 

In a recent article by Jewett 3 the opinions of most American obstet- 
ricians on this subject are quoted, from which it appears that most of 
them do not employ the prophylactic douche ; and that, while a certain 
number of them theoretically believe in auto-infection, they practically 
act as if its occurrence were impossible. 

Frequency. It is very difficult to make accurate statements as to the 
frequency of puerperal infection, especially when it occurs outside of 
hospital practice ; for the consideration of the vital statistics of the health 
officers of the various cities fails to give any idea as to the frequency 
with which the disease occurs, because the vast majority of deaths from 
it are not reported as such, but as malaria, typhoid fever, pneumonia, 
etc. ; for the laity have learned that puerperal fever is a preventable 
affection, and when it occurs are inclined to lay the blame upon the 
physician in charge of the case, which he usually attempts to shirk by 
stating that death was due to some other affection. 

That the tables prepared by the various health officers give no idea as 
to the frequency of death from puerperal infection is made very evident 
by the statement of Reynolds, 4 who in 1893 attempted to write an 
article upon the prevalence of puerperal fever in Boston. But on look- 
ing over the statistics furnished by the health office he found that he had 
seen during that year, if the reports of the department were accurate, 
more than one-fourth of all the cases of this character in Boston. Rey- 
nolds himself saw 28 cases in hospital and consultation practice, with 7 
deaths; and it is evident that many more than 28 women died from the 
affection in Boston during that time. 

Since the introduction of antiseptic and aseptic methods into midwifery 
the mortality from puerperal infection has diminished very markedly in 
hospital practice. In the old maternity of Paris and in the lying-in 
hospital of Vienna it was not at all infrequent to find years in which 
the mortality from this affection varied between 10 and 15 per cent, of 
all the women entering the institution. Just before the introduction of 
antiseptic methods the frightful mortality occurring in such institutions 
attracted the attention of the public at large, and steps were being insti- 
tuted to abolish them as a menace to public health. With the introduc- 
tion of aseptic methods, however, all this has changed, and in well-regu- 
lated lying-in institutions at the present time the mortality from sepsis 
is usually only a fraction, and a small fraction at that, of 1 per cent. 
And at present, in the discussions on puerperal infection, at least as far 

1 Kronig. Klinische Versuche iiber den Einfluss der Scheiden-spiilungen Aviihrend der Geburt 
auf den Wochenbettsverlauf. Miinchener med. Wochen., 1890, No. 1. 

2 Bretschneider. Klinische Versuche iiber den Einfluss der Scheidenspulungen Aviihren der 
-Geburt auf den Wochenbettsverlauf. Arch. f. Gyn., 1901, lxiii. 453-71. 

3 Jewett. The Question of Puerperal Self-infection. Amer. Gyn. and Obst. Journ., 1896, viii. 
417-429. 

4 Reynolds. The Frequency of Puerperal Sepsis in Massachusetts, etc. Boston Med. and Surg. 
Journ., cxxxi. 153-155. 



606 PATHOLOGY OF THE PUERPERIUM. 

as hospitals are concerned, the question is one of morbidity, namely, the 
number of patients whose temperature during the puerperium rises above 
38° C. or 100.4° F., rather than of mortality. 

On the other hand, in private practice it is questionable whether the 
results of to-day are materially better than before the introduction of 
antiseptic methods. At the present time we rarely hear of epidemics of 
puerperal infection such as occurred previously, and which we find men- 
tioned in the historical work of Hirsch, 1 who gives us the particulars of 
216 epidemics occurring between the years 1652 and 1862. 

At the same time, it would appear to us that puerperal infection is 
almost as frequent in private practice now as fifteen years ago, for the 
reason that the doctrines of asepsis have not yet permeated the rank and 
file of medical men, much less those of the midwives, in whose hands a 
very large proportion of all obstetrical cases occur. 

Bacon, 2 in a recent article, based upon the records of the health depart- 
ment of Chicago, shows that puerperal infection still plays a very promi- 
nent part in the death list. His statistics embrace the last forty years, 
during which period he estimates that 12.75 per cent, of all women dying 
between the ages of twenty and fifty years succumbed to puerperal sepsis. 
In 1873, 20 per cent, of all women dying between these ages perished 
from it. Since then the mortality has gradually fallen, reaching 6 per 
cent, in 1892, at which figure it has since remained, reaching 7.3 per 
cent, in the year 1895. These results are substantiated by those of 
Ingerslev, 3 who states that even at the present time in Denmark puerperal 
infection is the most frequent cause of death in women between the ages 
of twenty and fifty years, with the single exception of tuberculosis. 

Boxall, 4 in an article on the mortality of childbirth, which appeared 
in the Lancet in 1893, has tabulated the statistics of the Registrar Gen- 
eral's Office for forty-five years — that is, from 1847 to 1892. His tables 
give the average mortality for every 100,000 confinements for Englaud 
and Wales, for London, and for the provinces, aud in this way he is able 
to accentuate the difference between the results in London itself and the 
counties. He then divided his statistics into those occurring before 1860 
and those occurring since 1880, so as to permit of comparison between 
the results obtained in the pre-antiseptic and antiseptic eras. And he 
found that in London the deaths in childbirth from all causes had decreased 
since 1880 from 54 to 37 deaths per 100,000; but that this decrease was 
due almost entirely to the decrease in the number of deaths from the 
accidents of childbirth, and to a better and prompter application of 
instrumental procedures; while in the counties the death-rate from all 
causes is nearly as great as it was thirty years ago, thus showing that 
the application of antiseptic and aseptic methods had not permeated the 
ranks of the profession, and that outside of the lying-in hospitals the 
results are as bad to-day as twenty or even forty-five years ago. 

In considering the frequency of puerperal infection we should not be 
guided altogether by the consideration of its mortality, for the largest 
proportion of these cases do not result in death. But any one who has 

1 Hirsch. Historiseh-pathologiscbe Untersuehungen tiber Puerperalfieber. Erlangen, 1864. 

2 Bacon. The Mortality from Puerperal Infection in Chicago. Amer. Gvn. and Obst. Journ., 1896, 
viii. 429-446. 

3 Ingerslev. Die Pterbllchkeit an Wocbenbettfieber in Danemark und die Bedeutung der Anti- 
septik fur disselle. Zeit. f. Geb. u. Gvn., 1893, xxvi. 443. 

* Boxall. The Mortalitv of Childbirth. Lancet, 189:'., ii, 9-15. 



PUERPERAL INFECTION. 607 

had an opportunity of observing a number of gynecological cases cannot 
fail to be impressed with the very large proportion of cases coming into 
his hands which owe their origin to febrile affections during the puerpe- 
rium, which are preventable for the great part, and are due to the neglect 
of aseptic precaution on the part of the physicians in charge. 

Symptomatology. According to the statements of Labadie-Lagrave 
and Basset, 1 we rarely meet with the virulent forms of puerperal infec- 
tion with which our predecessors had to deal. They consider that in 
the vast majority of cases we meet with attenuated forms of the affection, 
whose modified course, in all probability, is due to the more or less rigor- 
ous application of antiseptic principles, which results in a diminution of 
the virulence of the offending organisms. According to them, in the 
cases of sepsis without definite localization, the symptoms are not so 
severe as formerly, and a considerable number of patients recover; while 
in other cases the infection does not make its appearance until the latter 
part of the puerperium, and then only in a comparatively mild form. 

As stated when considering the pathological anatomy of puerperal 
infection, its most usual manifestation is an endometritis, which may be 
either of the septic or putrid variety. The symptoms vary considerably 
according to the form with which we have to deal, and we shall first 
consider those of the septic variety. 

In the cases of septic endometritis everything goes smoothly for the 
first three or four days of the puerperium, when our patient, who thus 
far has done perfectly well, suddenly experiences more or less malaise, 
possibly has a headache, and toward the end of the third or fourth day a 
chill, after which the temperature rises to 103° F. or more. Generally 
the chill occurs but once, while the temperature remains constantly ele- 
vated. At the same time there is considerable tenderness in the lower 
part of the abdomen, the uterus is larger and more doughy in consistency 
than it should be, and is more or less sensitive on pressure. The lochia! 
discharge is usually increased in quantity, and is a bloody, more or less 
purulent secretion, which in the purely septic forms is practically devoid 
of color. If the temperature is very high, it is not infrequently dimin- 
ished in amount, and may occasionally almost disappear. The absence 
of odor from the uterine discharges in these cases is of the greatest 
practical importance, for the average practitioner associates puerperal 
infection with profuse and foul-smelling lochia ; while the fact is that 
in the most virulent cases, and especially those due to pure streptococcus 
infection, there is very little, if any, odor to be noticed. 

Another point of importance is the faulty involution of the uterus. 
This must be looked upon as a factor which plays an important part in 
the further spread of the disease ; for, as we have already stated, the 
micro-organisms make their way from the endometrium through the 
muscular walls of the uterus by means of the lymphatics, and, when the 
uterus is markedly relaxed, it is apparent that the lymph-channels must 
be more patent and offer far less resistance to their outward passage than 
when the uterus is firmly and normally contracted. 

The further history of septic endometritis varies according as the pro- 
cess remains limited to the cavity of the uterus or extends beyond it. 

1 Labadie-Lagrave and Basset. La septicemic puerperale attenuee (etude bacteriologique). Con- 
gres period, internat. de gyn. et d'obstet., 1892. Brux., 1894, i. 319-325. 



608 PATHOLOGY OF THE PUERPERWM. 

If it remains limited to the uterus, the temperature gradually falls, the 
secretion becomes less and less, and the patient is slowly restored to 
health. In the majority of cases, however, the uterine mucosa is not 
restored to its normal condition at once, but for a long time remains in a 
condition of subacute or chronic inflammation. If, on the other hand, 
the process extends beyond the uterus, the symptoms will vary according 
to the organs involved, and the clinical picture will be complicated by 
the appearance of symptoms characteristic of a parametritis, peritonitis, 
or pyaemia. 

The symptoms of putrid endometritis vary considerably from those of 
the septic form. In this we likewise have the initial chill and the high 
temperature, but the patient's condition does not usually appear so seri- 
ous. But the main difference between the two varieties of the affection 
is to be noted in the character of the uterine discharge, which in the 
putrid cases is abundant, very foul-smelling, and frequently contains 
large numbers of gas bubbles, which give it a frothy appearance. These 
cases usually recover, and only in rare instances give rise to a fatal 
termination. 

Between these two well-marked classes of cases, however, there exist 
all forms of gradation, for we frequently have to deal with a mixed infec- 
tion due to pyogenic as well as putrefactive organisms. 

As already indicated when considering the pathological anatomy of 
the puerperal ulcer, it is not infrequent to find the chill and rise of tem- 
perature associated with an ulcer about the vulva or somewhere in the 
vagina. In the vast majority of cases, however, the puerperal ulcer does 
not occur alone, but is usually associated with an endometritis. The 
same may be said of puerperal vaginitis, for it is extremely rare for the 
infection to be limited to the vagina. 

If the process has extended from the uterine cavity or from ulcers 
about the cervix to the parametrium, we meet with symptoms which are 
more or less characteristic of the affection. In many cases the initial 
rise of temperature gradually disappears, and we are congratulating our- 
selves that our patient has escaped so easily, when suddenly there is a 
chill and the temperature rises again, and then pursues a more or less 
irregular course, usually marked by exacerbations in the evening. 

This may continue for a longer or shorter period without any local 
manifestation, but sooner or later, on abdominal palpation, we feel a mass 
arising on one or both sides of the uterus, which is due to abscess forma- 
tion within the folds of the broad ligament. This abscess may be limited 
to the broad ligament itself, or may follow the lymphatics of the pelvic 
connective tissue along the anterior portion of the pelvis up to the neigh- 
borhood of Poupart's ligament, or extend backward toward the retro- 
peritoneal region. The temperature will continue until the abscess has 
ruptured spontaneously or been opened with the knife, except in a few 
cases in which it undergoes gradual resorption, leaving a mass of cica- 
tricial tissue to mark its former situation. Unless the parametritic 
abscess ruptures into the peritoneal cavity, the patients usually recover. 
If not operated upon, the abscess may burst into the rectum or bladder, 
and occasionally through the abdominal wall in the inguinal region. 

In a certain number of cases the infection extends from the uterine 
cavity to the Fallopian tubes, and there gives rise to a salpingitis with 



PUERPERAL INFECTION. 609 

its accompanying symptoms, and many a case of pyosalpinx, which is 
operated upon later, is the result of such a process. 

Unfortunately, in a considerable number of cases, the infection does 
not remain limited to the uterus or the parametrium, but the micro- 
organisms make their way through the lymphatics of the muscular wall 
of the uterus to the peritoneum, where they give rise to a peritonitis. 
In rare instances the peritonitis is the result of extension of the process 
from the tubes, and in still other cases to the rupture of a parametritic 
abscess or pyosalpinx. 

In a small number of cases the peritoneal involvement is limited to 
the portion lining the pelvic cavity, when we have to deal with a 
pelvic peritonitis. If the process remains limited, the chances are that 
it will eventuate in recovery; but if a greater portion of the peritoneum 
be involved, the death of the patient is to be predicted. The charac- 
teristic symptoms of peritonitis may make their appearance at almost 
any time during the puerperium, but rarely before the third or fourth 
day, or later than the end of the first week, unless it be due to the rupt- 
ure of an abscess. 

When the patient is infected with virulent streptococci, the endo- 
metritic involvement is usually very slight, and the first sign of infec- 
tion appears from the side of the peritoneum. Here we notice the chill 
and the high temperature, which remains constantly elevated; the pulse 
becomes rapid and in the latter part of the affection very weak and 
thready. The patient complains of intense pain, which is at first limited 
to the lower portion of the abdomen, but gradually extends over the 
entire abdomen. At the same time there is marked tympanites, and the 
abdominal walls are rendered firm and tense by the distended intestines. 
If a fatal issue ensues, death usually occurs within the first ten days of 
the puerperium, the patient gradually sinking and dying in a conscious 
condition. 

In the cases of pyaemia, on the other hand, where the organisms 
have made their way into the venous channels, the clinical picture is 
very different. Here the initial chill does not occur so soon and the 
temperature does not remain constantly elevated, but instead we have 
a typical hectic fever, with the alternating chill, high temperature, and 
remission. The symptoms of pyaemia vary very considerably, according 
as it is the result of the dislodgement of a single thrombus, or of the 
constant supply of the blood with small portions of infected thrombi. 
In the first instance we have a metastasis produced at some one point, 
whose symptoms will vary according to the organ involved. On the 
other hand, if the thrombi are being constantly dislodged we may have 
symptoms referable to various organs. 

One of the most constant symptoms of pyaemia is an infectious broncho- 
pneumonia, which frequently leads to a fatal termination. In other cases 
we notice swellings at the various joints which frequently eventuate in 
suppuration and lead to their total destruction. The course of pyaemia 
varies very materially according to the organs involved and the power 
of resistance of the patient, and is nothing like so uniformly fatal as the 
peritonitic form of infection. 

In a certain number of cases, the infection is so virulent that the organ- 
isms do not have a chance to become localized in any one organ, and we 

39 



610 PATHOLOGY OF THE PUERPERIUM. 

find them and their toxins in very large numbers in the blood, with very 
slight involvement of the uterus. This we designate as septicaemia, 
which is the most rapidly fatal form of infection ; the patients in many 
instances dying on the second or third day of the puerperium in a con- 
dition of shock, and without the development of local symptoms, the 
writer having recently observed a case of pure streptococcus infection in 
the out-patient department, which ended fatally eighteen hours after the 
initial rise of temperature. 

In a small number of cases infected thrombi, instead of going to the 
lungs or other organs, make their way into the femoral vein and there 
give rise to phlegmasia alba dolens. This usually does not make its 
appearance until some time in the second week of the puerperium, or later, 
when the patient begins to complain of more or less pain in the line of 
the femoral vessels in one limb and soon notices a swelling of the part, 
which extends from above downward. This affection is extremely pain- 
ful and usually lasts for a considerable time, but does not lead to death 
unless some complication occurs. In many cases of phlegmasia the onset 
of the disease is associated with pain about the chest. This symptom 
has been dwelt upon by Pinard and AY allien 1 in their recent work on the 
treatment of puerperal infection, and attributed by them to the involve- 
ment of the pleurae by small thrombi, which gives rise to isolated areas 
of pleurisy. 

In a certain number of cases, infection may occur before the birth of 
the child. These we designate as " infection intra-partum." This 
usually occurs in slow labors in which the membranes are ruptured at 
an early period. In these cases the temperature may be markedly ele- 
vated and the patient present a markedly septic appearance during the 
progress of labor. When the temperature during labor rises above 
100.5° F. we should always think of this complication, which should 
indicate its speedy termination. 

Diagnosis. The diagnosis of puerperal fever does not usually offer any 
difficulty to the physician in charge, as the clinical history is very signifi- 
cant. 

If a patient who has been previously well has a chill and rise of tem- 
perature on the third or fourth day of the puerperium, we may be 
practically sure that we have to deal with an infection, unless we can 
account for the symptoms by some other perfectly apparent cause. In 
many cases the initial chill does not occur, and we simply have the rise 
of temperature, and we may say in general terms that a temperature of 
100.4° F. or higher, w T hich persists for more than twenty-four hours, is, 
a priori, evidence of infection. 

In the old times it was believed that the onset of the lacteal secretion 
was accompanied by fever, and the older observers always looked for a 
rise of temperature on the third or fourth day, and designated it as 
" milk fever." At the present time, however, we no longer believe in 
its occurrence, as we know that the normal puerperium should be abso- 
lutely free from fever. It is customary, in speaking of the puerperium, 
to consider a rise of temperature to 1*00.4° F. or 38° C, as within the 
bounds of normal. But when this point is reached we are obliged to 

1 Pinard and Wallich. Traitement de 1'infection puerperale. Paris, 1896. 



PUERPERAL INFECTION. 611 

look for some cause for the temperature, which in the vast majority 
of cases will be found in an infection from without. 

After the infection has become well established, either as endome- 
tritis, peritonitis, or one of the other forms, the diagnosis is usually 
easy. In the cases of puerperal endometritis in which there is no 
involvement of the perimetrium or parametrium, usually very little 
pain is observed, and it occasionally becomes a difficult matter to decide 
positively whether the temperature is due to a uterine infection or to 
some other cause. 

In a certain number of instances, we may observe a rise of temperature 
on the third or fourth day of the puerperium, which may be due to 
mental causes, such as emotional excitement, fright, or grief. In such 
cases the temperature rises suddenly, and may reach a considerable 
height, and promptly falls within a few hours to the normal. These 
cases at the onset may simulate an infection, and it is only by the rapid 
subsidence of the symptoms that we are able to make a diagnosis. 

In a certain number of cases also, we may have a rise of temperature 
caused by auto-infection from the intestinal tract. Special attention 
has been devoted to this subject by Budin 1 and Galtier, 2 who state that 
in some instances such a condition may closely simulate puerperal infec- 
tion. The diagnosis is readily made, however, by the administration 
of a strong laxative, for after a copious movement of the bowels the 
temperature rapidly falls and remains at the normal line. 

We not infrequently notice a rise of temperature occurring in the early 
part of the puerperium, which is due to inflammatory troubles about the 
breasts, but the subsequent history of the case readily clears up the 
question of diagnosis. 

These are the most usual causes of rises of temperature during the 
puerperium which are not connected with puerperal infection. But 
many intercurrent affections may give rise to a chill and high tempera- 
ture, which for a short time may cause us to fear puerperal infection; 
but the subsequent history of the case soon teaches us that our fears are 
groundless. This is frequently the case in angina and the acute pulmo- 
nary affections, which may occur at any time during the puerperium. 
There are two diseases, however, which are frequently confounded with 
puerperal fever, and which are also made the scapegoat to shield the 
practitioner who has neglected aseptic precautions in the conduct of his 
case. These are malarial fever and typhoid fever. There is no doubt 
that either of these affections may occur during the puerperal period, 
but in the vast majority of cases the diagnosis is made to shield the 
practitioner from the consequences of his own neglect. 

Occasionally, in prolonged suppurative processes about the pelvis, we 
have symptoms which may readily be confounded with one or the other 
of these affections, but in the present state of our knowledge there is no 
reason why we should long remain in doubt as to the cause and origin of 
the fever in a given case. 

If we have to deal with malaria, we should be able to demonstrate in 
the blood the presence of the malarial plasmodium, and, unless the bJood 
has been carefully examined and the malarial organism demonstrated, 

i Budin. La Semaine med., 1896, 155. 

2 Galtier. De l'infection primitive du liquide amniotique apres la rupture prematuree des mem- 
branes de l'oeuf humain. These de Paris, 1895. 



612 PATHOLOGY OF THE PUERPERIUM. 

we do not consider that one is justified in regarding as malarial any 
puerperal patient who has an elevated temperature and an occasional chill. 

The writer in his own practice goes still further than this, and would 
not attribute a rise of temperature in the puerperium to malaria to the 
exclusion of puerperal infection, unless he had conclusively demonstrated 
the presence of the malarial organisms in the blood of the patient, and 
likewise demonstrated by cultural methods that the uterine cavity was 
free from all pathogenic organisms; for it is possible that in a certain 
number of cases we may have puerperal infection associated with mala- 
rial poisoniug, and under such circumstances, without the bacteriological 
examination of the uterine lochia, we would be satisfied of the malarial 
origin of the symptoms upon finding the plasmoclium in the blood; whereas 
it in reality only explains a portion of the symptoms. Judged by these 
criteria, malaria complicating the puerperium will occur far less fre- 
quently than is at present said to be the case; but there is absolutely no 
doubt that it occasionally occurs, as the writer recently demonstrated in 
his own work. In this case we were able to demonstrate the presence 
of quartan malarial organisms in the blood of the patient, and at the 
same time to demonstrate the absolute sterility of the uterine lochia. 

The diagnosis of typhoid fever is very frequently made in the post- 
puerperal infections, and is based by the average observer upon the long- 
continued fever and the general prostration of the patient. The writer, 
while he believes that in rare instances typhoid fever may complicate the 
puerperium, as well as any other condition, is confident that only a small 
proportion of the cases which are thus designated are really typhoid in 
origin, but that most of them depend upon the uterine infection. And 
in the present state of our knowledge, especially since WidaPs discovery 
of the agglutinative action of the blood serum of typhoid patients upon 
cultures of typhoid bacilli, we are not justified in making a diagnosis of 
typhoid fever unless this specific action can be demonstrated. And we 
might say that every rise of temperature during the puerperium should 
be regarded as due to infection unless we can clearly demonstrate some 
other affection to hs its cause. Occasionally typhoid fever occurring 
in the puerperium may so simulate an infection that a diagnosis of 
puerperal fever will be made. Jung has recently described several 
cases in which the mistake was made, the true nature of the malady not 
being recognized until autopsy. 

Therefore, in making a diagnosis of any affection complicating the 
puerperium, an accurate and complete physical examination of the patient 
is necessary, and it should be combined with all the aids which the recent 
advances in microscopy and bacteriology have placed at our command. 

As we have already stated, the most common form of puerperal infec- 
tion is an endometritis, which is either of the putrid or septic variety, 
and it is a matter of the greatest possible importance to decide with which 
we have to deal. In many cases the clinical symptoms will indicate 
with tolerable accuracy whether we have to deal with a saprsemic or 
septic condition ; but the only method by which we can arrive at a posi- 
tive conclusion is by taking cultures from the interior of the uterus, 
when we will obtain putrefactive organisms in the saprsemic form, and 
the pyogenic organisms, and especially the streptococcus, in the septic 
forms. When the infection is due to the gonococcus, the development 



PUERPERAL INFECTION. 



613 



of a purulent ophthalmia on the part of the child affords a ready method 
of diagnosis. But even in such cases one is not sure that it is the only 



organism concerned. 



Fig. 359. 



Fig. 360. 



Fig. 361. 








Cultures may be taken from the interior of the uterus with compara- 
tively little difficulty by means of the lochial tube, which was first intro- 
duced by Doederlein, 1 and which consists of a glass tube 20 to 25 cm. in 
length aud 3 to 4 mm. in diameter, with a slight bend at one end so as to 
conform to the anteflexed conditiou of the uterus. It is sterilized either 
by dry heat or steam, and is then ready for introduction. In practice 
the most convenient method for sterilizing the tube and enabling us 



1 Doederlein. 
der Vagina gesunder und krauker Wochnerrinnen 



Untersuchung uber das Vorkomen von Spaltpilzen in den Lochien des Vterus und 

Arch. f. Gyn., 1887, xxxi. 412. 



614 PATHOLOGY OF THE PUERPERIUM. 

to carry it with us in a sterile condition is to place it in a long test-tube 
of thick glass, which contains at its lower extremity a small amount of 
cotton, and whose upper end is filled by a cotton plug, just as one closes 
the ordinary culture tubes which are employed in bacteriology. The 
locbial tube is then sterilized within the test-tube, and may thus be carried 
from place to place without fear of contamination. 

When we wish to make cultures from the uterus, our hands and the 
external genitalia should be thoroughly disinfected, the patient placed 
in Sims' s position, and a sterilized Situs's or Simon's speculum introduced 
so as to retract the posterior vaginal wall, then the cervix caught with 
a sterile volsellum forceps and brought down to the vulva. Its vaginal 
portion is then carefully cleansed with a bit of sterilized cotton, and the 
sterile lochial tube is removed from its container and introduced into the 
uterus as high up as it w 7 ill go, care being taken to avoid touching the 
external genitals in the operation. To the end of the tube, wdiich pro- 
trudes from the vulva, a syringe, which draws well, is attached by 
means of a rubber tube. Suction is made, whereby a certain amount 
of the uterine contents is drawn up into the tube. The tube is then 
removed and its ends sealed with sealing wax and replaced in its con- 
tainer, when it can be carried without fear of contamination. On reach- 
ing the laboratory it is broken in its middle portion and cultures taken 
from its contents. Fig. 359 shows the lochial tube within its test-tube, 
Fig. 360 the tube ready for use, with the syringe attached, and Fig. 361 
the tube sealed and ready for transportation to the laboratory. 

While this method appears somewhat complicated, it can readily be 
carried out by any one who is conversant with the ordinary rules of sur- 
gical technique, and the tube then sent to the laboratory for examination. 
By this means we are able within twenty-four hours to know with cer- 
tainty whether our infection is due to saprsemic or pyogenic organisms, 
and whether we have to deal with a comparatively harmless or a danger- 
ous affection. 

Marmorek 1 in his article on the anti-streptococcus serum strongly 
urges the bacteriological examination in every case of puerperal infection. 
The writer makes it a part of the routine examination in every case 
presenting a rise of temperature above 101°, and the satisfaction of 
knowing exactly with what form of infection he may have to deal amply 
repays him for the trouble taken, and at the same time gives him impor- 
tant indications as to treatment. 

Pinard, 2 in his recent work on puerperal infection, scoffs at the idea of 
bacteriological examinations in puerperal fever, and states that "they 
are beyond the scope of any except trained bacteriologists." But the 
writer's personal experience is opposed to this ; and he believes that 
this method of diagnosis can be adopted by any one who knows how 
to disinfect his hands and who lives within reach of a competent 
bacteriologist. 

Just after removing the lochia by the lochial tube it is the writer's 
practice, provided the cervix is sufficiently patulous, to introduce his 
sterile finger into the uterus and feel its interior, after which a douche 
of several litres of natural salt solution should be given. This pro- 

• a RQQ r M 0rek# Le stre P t0C °q U8 et le serum antistreptococcique. Annales de l'lnst. Pasteur, 1895, 
- Pinard and Wallich. Traitement de 1' infection puerperale. Paris, 1896. 



PUERPERAL INFECTION. 615 

cedure gives us very important information, and enables us in many 
eases to predict in advance the result of the bacteriological examination, 
and gives us important information as to the line of treatment to be 
pursued. 

In the vast majority of cases in which we have to deal with putrid 
endometritis and those forms due to the colon bacillus, we usually find 
the surface of the uterus rouffh and covered bv shreds of broken-down 
tissue ; while in the septic forms of endometritis, and especially those 
due to virulent streptococci, the interior of the uterus is frequently per- 
fectly smooth. 

The mere inspection of the lochial discharge is also of considerable 
value, for in the cases of putrid endometritis it is frothy and frequently 
very offensive in odor, while in the cases of pure streptococcus infection 
it is very little changed from the normal. This distinction is of impor- 
tance, because the first question which the practitioner usually asks 
of the nurse, in the presence of fever in the puerperium, is whether the 
lochia are foul-smelling or not, and, if he receive a negative answer, he 
feels fairly sure that the fever is of other than uterine origin; whereas 
almost the reverse is true, and, as a rule, the fouler the odor, the less 
is the danger to which the patient is exposed, and vice versa. 

"When the process has extended beyond the uterus, the diagnosis is 
much more readily made, and with the exception of malaria, typhoid, 
and acute miliary tuberculosis, no one can mistake the symptoms pro- 
duced by a peritonitis or by a pyaemia. In the cases of parametritis 
and suppurative affections of the tubes and ovaries, the vaginal exami- 
nation will demonstrate the presence of a tumor mass on one or the 
other side of the uterus, if the tumor has not already made itself evi- 
dent to abdominal palpation. 

Treatment. Preventive. In considering the treatment of puerperal 
fever, prophylaxis should occupy the most important place. As has 
been repeatedly pointed out in the course of this article, puerperal infec- 
tion is wound-infection, and is due to the introduction of pathogenic 
micro-organisms by the hands or instruments of the doctor or nurse. 
Therefore, the most scrupulous asepsis during the conduct of labor is 
the means upon which we have to rely to limit its occurrence. Every 
physician who conducts a labor case should strongly feel his personal 
responsibility in this connection, and he does not do his full duty to his 
patient unless he regards the rules of asepsis as carefully as when per- 
forming a capital surgical operation. 

The first point, therefore, in the prophylaxis of puerperal infection is 
the coasideration of the preparation of the patient and the disinfection 
of the hands and instruments of the accoucheur. 

At the onset of labor the patient should receive a full bath and a rectal 
enema. And before each and every vaginal examination the external 
genitals, and especially the region about the perineum and anus, should 
be most scrupulously washed with soap and hot water and then rinsed in 
1 : 1000 bichloride solution, after which a pledget of absorbent cotton 
or a towel soaked in the same solution should be placed over the vulva 
and allowed to remain there until the physician is ready to make the 
examination, remaining in place for at least three minutes. If an opera- 
tive procedure is to be undertaken the buttocks of the patient should 



(JIG PATHOLOGY OF THE PUEBPEBIUM. 

be placed upon sterilized towels or sheets, and the legs of the patient 
enveloped in the same manner, so as to avoid the possibility of contami- 
nating the hands by organisms adhering to the bedclothes or clothing of 
the patient. If sterilized towels are not at hand, freshly washed towels 
taken directly from the drawer should be used. 

The best method of hand-disinfection has for a long time been a matter 
of dispute, and observers have not yet agreed as to the most practicable 
means of rendering the hands sterile. It may, however, be definitely 
stated that any method which will render the hands sterile, or even 
comparatively so, will require at least ten minutes. 

The rapid method of hand-disinfection which was introduced by Fiir- 
bringer, 1 by which, it was stated, the hands could be rendered abso- 
lutely sterile in three minutes, has been shown by later experiments to 
be absolutely inefficient. And the rapid method of hand-disinfection by 
means of alcohol, which was introduced by Reinicke 2 in Zweifel's clinic 
in Leipsic, has been shown, by the careful work of Menge and Kronig, 
to be based upon a fallacy, as they showed that the alcohol did not pos- 
sess a markedly germicidal action, but simply produced conditions in the 
skin which for the time being rendered it difficult to remove the organ- 
isms from the surface of the hands. 

At the present time the best method of hand-disinfection with which 
the writer is familiar is the one introduced by Dr. Halsted at the Johns 
Hopkins Hospital some years ago, and described by Dr. Kelly. 3 

Bacteriological examination shows that it is capable of yielding better 
results than any other method, though in a certain number of cases it 
fails to produce absolutely sterile hands. The following directions are 
copied from the regulations for hand-disinfection which are posted over 
every wash-basin in the lying-in ward of Johns Hopkins Hospital : 

1 . Cut the finger-nails with clippers or scissors to 1 mm. in length. 

2. Scrub the hands and forearms up to the elbows vigorously w T ith 
nail-brush, green soap, and hot water for at least five minutes by the 
clock, or until they are macroscopically clean, paying especial attention 
to the nails and palmar surface of fingers. The water must be changed 
at least once. After changing it, remove dirt from beneath the nails with 
nail cleaner or penknife, and then renew the washing. 

3. Rinse the hands in fresh water, soak then in a hot saturated solu- 
tion of potassium permanganate until they take on a deep mahogany- 
brown color. 

4. Dissolve this off in a hot saturated solution of oxalic acid. 

5. Then soak the hands and forearms in a 1 : 1000 bichloride solution 
for three minutes by the clock. 

6. Touch nothing until ready to examine the patient, going directly 
from the bichloride solution to her. 

The only objections which can be made to this method of hand-disin- 
fection are the length of time which it requires and the roughness of the 
hands which is sometimes produced by it. The first objection cannot be 
overcome, as the writer does not believe any one can thoroughly disinfect 

1 Fiirbringer. Untersnchungen und Vorschriften liber die Desinfection der Hande des Arztes nebst 
Bemerkungen liber den bakteriologischen Charakter des Nagelschmutzes. Wiesbaden, 1888. 

- Reinicke. Bakteriologische Untersuchungen uber die Desinfection der Hande. Arch. f. Gyn., 
1895, xlix. 515-558. 

3 Kelly. Hand Disinfection. Amer. Journ. Obst., 1891, xxiv. No. 12. 



PUERPERAL INFECTION. 617 

his hands in less than ten minutes, whether one uses permanganate and 
oxalic acid or not. The second objection can be obviated to a consid- 
erable extent bv anointing the hands with a glycerin ointment after the 
examination is made. As we know that even the most vigorous methods 
of hand-disinfection do not render the hands absolutely sterile, it has 
been suggested that this object may be attained by the use of thin rubber 
gloves. For this purpose the gloves are thoroughly boiled and then 
drawn over the carefully disinfected hands ; and as long as they remain 
intact we are certain that bacteria which are upon the hands cannot 
lead to infection of the patient. The gloves, however, interfere consid- 
erably with the sense of touch, and therefore we do not recommend 
their employment, except when we are not sure as to the condition of 
our hands. They should always be worn when the hands have recently 
come in contact with pus or infectious wound secretions. 

As long as vaginal examinations are made, no matter how carefully 
we have attempted to disinfect our hands, infection will occasionally 
occur. This is due partly to the fact that hand-disinfection under some 
circumstances is much more difficult than is generally believed and partly 
to the unwitting contamination of our hands before making the exami- 
nation. In many cases, even when gloves are used, bacteria may be 
carried from the vulva into the vagina by the examining finger, as is 
clearly shown by the experiments of the writer, which were mentioned in 
considering: auto-infection. Therefore vaginal examinations should be 
limited in number as much as possible, and in normal cases one or two 
are all that is necessary, if the accoucheur is acquainted with the methods 
of external examination. 

In a large number of cases, labor can be conducted with absolute 
safety and ease by means of external manipulations alone, without a 
single vaginal examination. And the writer believes that the only value 
of the latter during labor is to ascertain the degree of dilatation of the 
cervix and to estimate the probable duration of labor. All other points 
for which we seek information by vaginal examination are made out 
far more clearly by the external examination, and were we to be 
debarred from one or other form of examination, we would prefer to 
give up the vaginal. 

The recent articles of Leopold and Sporling, 1 and Leopold and Orb, 2 
show the extreme accuracy of external examination, and they state that 
it is possible from their own experience to deliver at least 90 per cent, 
of all cases by means of the external examination. Their observations 
show that the number of errors in diagnosis become more and more 
infrequent as the obstetrician becomes better trained in this mode of 
examination ; for example, in the first 1000 cases which they delivered 
by this means there were 6.5 per cent, of errors of diagnosis, whereas 
in the last 1000 cases the errors were reduced to 1.77 per cent. 

This clearly shows us what can be accomplished by external examina- 
tion alone, and its importance cannot be too strongly urged upon the 
accoucheur. It is perfectly harmless, and cannot offend the sense of 
modesty of the patient, and can be employed as often as desired, and, 

1 Leopold and Sporling. Die Leitung der regelmassigen Geburten nur dnrch iinsseren Untersuch- 
ungen. Arch. f. Gyn., xlv. 339-371. 

2 Leopold and Orb. Die Leitung ganz normaler Geburten nur durch iiussere Untersuehung. 
Arch. f. Gyn., 1895, xlviii. 304-323. 



618 PATHOLOGY OF THE PUEBPERIUM. 

unlike digital examination, does not require the laborious hand-dis- 
infection. This method of examination should always be employed to 
the exclusion of the vaginal examination whenever the vaginal secretion 
presents an abnormal appearance which leads us to suppose that it con- 
tains pathogenic micro-organisms. But still more important is its em- 
plovment in cases when the accoucheur is not sure of the cleanliness 
of his own hands, as after intra-uterine manipulations with puerperal 
sepsis and the performance of autopsies upon septic cases, etc. Under 
such circumstances the vaginal examination should be resorted to 
only in case some marked complication arise during the course of 
labor. 

In view of what has already been stated concerning the bacterial 
contents of the vagina, and the result of experiments by Leopold 1 and 
others with the prophylactic vaginal douche, and also as the result 
of his own personal experience, the writer strongly advises that the 
prophylactic douche be not employed as a matter of routine, but that it 
be resorted to only when the vaginal secretion presents marked evidences 
of abnormality. 

All that has been said concerning the necessity of cleanliness and asep- 
sis on the part of the physician applies equally well to the nurse, and she 
should be strictly forbidden to make vaginal examinations or give douches 
except at the direct request of the physician in charge ; otherwise, we 
have no means of knowing, in case infection ensues, whether it is the 
result of our own carelessness or not. 

During the second stage of labor it is well to have the vulva covered 
by an aseptic pad, in the form of a towel soaked in bichloride solu- 
tion. This is done not so much for fear of infection from the air 
as to prevent the possibility of the patient contaminating herself with 
her hands. 

The third stage of labor likewise offers many facilities for infection, 
and too much stress cannot be laid upon its proper conduct ; and, 
generally speaking, the generative tract, after the birth of the child, 
should be regarded as a noli me tangere, except in cases of urgent 
necessity. 

Excepting severe hemorrhage and cases of adherent placenta, there is 
absolutely no indication for introducing the hand into the parturient 
tract. I believe that the frequency of'adherent placenta is very grossly 
over-estimated, and in many cases its occurrence is due to the injudicious 
employment of Crede's method. The writer's practice is to watch the 
fundus of the uterus by placing his hand gently upon it, but not knead- 
ing it. After the lapse of ten or fifteen minutes, as a rule, we notice 
that the fundus rises about 5 cm. toward the umbilicus ; this means that 
the placenta has been detached from the uterine wall and has been 
expelled either into the lower uterine segment or into the vagina. 
Under these circumstances it is ready for expression, the body of the 
uterus being simply used as a piston to force the detached placenta 
through the vagina. 

If after waiting half an hour the fundus uteri does not rise up, as 
described, we should then resort to the typical Crecle method of expres- 

l Leopold. Vergleichende rntersuehungen iiber die Entbehrliehkeit der Scheidenausspiilungen 
bei panz normalen Ueburten und iiber die' sogenannte Selbstinfektion. Arch. f. Gyn„ 1894, xlvii. 
580-635. 



PUERPERAL INFECTION. 619 

sion. Observance of these directions will show that adherent placenta 
is of very rare occurrence, indeed, and will not necessitate the introduc- 
tion of the hand in utero more than once in several hundred cases. 

The practice recommended by Grandin, 1 Palmer Dudley, 2 and others, 
who advocate routine vaginal examination at the conclusion of the third 
stage of labor, to detect cervical tears, which they believe should be 
repaired immediately, cannot be too strongly deprecated, and those 
who follow their advice will surely find that a much larger proportion 
of their patients present abnormal puerperia than if they reserved the 
vaginal examination at the conclusion of the third stage of labor for 
exceptional and urgent cases. 

Another point in the prophylaxis of puerperal infection is attention to 
perineal tears, and every tear which extends deeper than the mucosa 
should be sutured immediately after the conclusion of labor, unless it be 
contraindicated by the general condition of the patient or by a very 
oedematous condition of the parts. To save time, it is the writer's 
practice to introduce the sutures immediately after the birth of the child 
and while waiting for the expulsion of the placenta. Their ends are 
then grasped by artery-forceps and are tied as soon as the placenta has 
been expelled. This method, beside saving considerable time, is also 
beneficial in that it gives us something to do during the third stage of 
labor, and does not so often expose us to the temptation of premature 
expression of the placenta. 

After the third stage is ended the patient should be cleaned and 
dressed with an aseptic vulval pad, which is held in place by a 
T-bandage. 

During the puerperium the external generative organs should be fre- 
quently cleansed with a 1 : 2000 or 1 : 4000 bichloride solution applied 
by means of an irrigator or on small pieces of cotton. The writer 
strongly deprecates the routine use of douches during the puerperium, 
and considers that they should be given only under exceptional circum- 
stances, and when employed should be given by the doctor himself, unless 
he has a nurse who is thoroughly versed in aseptic technique and upon 
whom he feels he can confidently rely. In several cases the writer has 
seen infection in the later periods of the puerperium follow the use of 
dirty syringes in the hands of a nurse. 

Curative. When we come to the consideration of the curative treat- 
ment of puerperal sepsis we have to deal with a question about which 
there is still a great deal of dispute, and what we shall say Avill probably 
stand in marked contrast to much of the current practice in this regard. 
If we find a puerperal ulcer about the perineum or lower portion of the 
vagina, the parts should be kept as clean as possible, and the ulcer occa- 
sionally touched with 50 per cent, carbolic acid or tincture of iodine. 
If the perineum has been repaired and its edges are suppurating, we 
should remove the stitches so as to obtain free drainage. 

Puerperal endometritis is the affection which we are called upon most 
frequently to treat, and it is here that the directions for treatment differ 
so greatly. 

1 Grandin. Late Infection in the Puerperal State ; being a plea for the routine manual examina- 
tion of the interior of the uterus after the completion of the third stage of labor. Trans. Amer. Gvn. 
Soc, 1895. xx. 462-468. 

2 Dudley. Immediate Repair of Lacerated Cervix. Trans. Amer. Gyn. Soc, 1895, xx. 343. 



620 PATHOLOGY OF THE PUERPERIUM. 

As soon as our patient's temperature reaches 102° or 102.5°, unless 
we can certainly exclude uterine infection, we should investigate the 
uterus. The hand should be carefully sterilized and, as indicated when 
considering the diagnosis of the affection, a certain amount of the lochia 
should be removed from the uterus for bacteriological examination, 
after which the sterilized index finger should be introduced into the 
uterine cavity, and its interior carefully palpated. Then a careful 
bimanual examination should be made to ascertain the condition of the 
appendages and the broad ligaments. If we find the uterine cavity 
perfectly smooth and not covered with shreds of broken-down tissue, we 
should give a douche of several litres of boiled water or normal salt 
solution, but should not think of curetting. On the other hand, if we 
find the interior of the uterus rough and jagged and containing more or 
less debris, it should be thoroughly cleaned out with the finger, followed 
by the curette, if necessary, after which the saline douche should be 
employed. The employment of the curette is not to be recommended in 
all cases of puerperal endometritis, for the reason that in many instances, 
and these are usually the most severe cases, there is absolutely nothing 
which can be removed by it, and its employment can only do harm by 
breaking down the leucocytic wall which is intended to prevent the 
ingress of organisms into the deeper layers of the uterus. If, however, 
the uterus contains debris, its removal by the finger or curette is 
indicated. 

The routine employment of the curette in all cases of puerperal infec- 
tion is advocated by most of the French and American writers. Pinard 1 
and Doleris 2 are particularly enthusiastic in this regard ; while the Ger- 
mans, on the other hand, reserve its use for exceptional cases, Fritseh's 3 
views representing the usual German doctrines on this subject. 

It will be noticed that nothing has been said about the employment of 
antiseptic douches in the treatment of puerperal endometritis. The writer 
regards the routine use of bichloride or carbolic injections in the treat- 
ment of these cases as productive of more harm than good. If we have 
to deal with septic endometritis produced by a virulent streptococcus, 
microscopical examination shows us that the organisms have penetrated 
far into the uterine wall by the time we get the initial chill and rise of 
temperature. Under these circumstances the employment of an anti- 
septic douche is not rational, as we know that it cannot reach the organ- 
isms in the uterine wall, which are giving rise to the symptoms and upon 
which the further spread of the disease is dependent. 

It has been shown experimentally by Bumm 4 that bichloride injec- 
tions penetrate the tissues to only a very slight extent. He took the 
liver of an animal dead of anthrax, soaked it for thirty minutes in a 
1 : 1000 bichloride solution, then placed it upon a freezing microtome 
and cut thick sections from it. After cutting off about -fa mm. he 
inoculated the next section into another animal, and found that it died 
from anthrax, thus showing that the antiseptic action of the bichloride 
was exerted only upon the surface of the tissues. If this be the case in 

1 Pinard and Wallich. Traitement de l'infection pu£rperale. Paris, 1896. 

2 Doleris. Curettage dans le sepsis puerperal. Nouv. Archives d'Obst. et de Gyn., Mai, Juin, 1886, 
Fev. Mars, 18H7. 

a Fritsch. Ueber Auskratzung des Uterus nach reifer Gebhrten. Zeit. f. Geb u. Gyn., 1891, xxi. 456. 
4 Bumm. Ueber die verschiedenen Ferulenzgrade der puerperalen Infektion und die lokale Behand- 
lung bei Puerperalrieber. Cent. f. Gyn., 1893, 975. 
& Bumm. Op. cit. 



PUERPERAL INFECTION. 621 

the laboratory, where the tissues are soaked in a bichloride solution for 
some time, what effect upon organisms lying in the muscle wall of the 
uterus can we expect from the passage of a few litres of bichloride solu- 
tion through its cavity? 

Bumm 1 likewise showed that the streptococci made their way through 
the uterus with great rapidity, and after infection in animals found that 
streptococci could travel 2 cm. or more in the space of six hours. What 
has been said concerning bichloride applies equally well to the other dis- 
infectants. 

Now, when we come to consider their employment in cases of putrid 
endometritis, we shall find it even less rational than before. In the 
vast majority of such cases simply cleaning out the uterus with the 
finger or curette will lead to a rapid Mill of temperature and the 
amelioration of symptoms. Our object in giving ^ douches in most 
of these cases is* simply to wash away debris which has been left 
behind by the curette or finger, and for this purpose sterile water is far 
better than any antiseptic fluid. The writer's results from this method 
of treatment are as good as those obtained by others who use the various 
antiseptic douches. In this opinion he is sustained by most of the men 
who have done bacteriological work in this connection, notably Bumm 2 
and Kronig. 3 The writer has treated 52 cases of streptococcic endo- 
metritis, with 2 deaths attributable to the disease, a mortality of less 
than 4 per cent. In 30 cases he had to deal with a pure streptococcic 
infection, and none of the cases died ; while in 12 cases the streptococcus 
was associated with the colon bacillus or other organisms, and 2 of the 
patients died. These results apparently bear out the conclusions of 
Bar and Tissier, that combined infection with the streptococcus and colon 
bacillus are much more dangerous than infections due to either organism 
alone. At the same time we do not desire to give the impression that 
pure streptococcic infections are not serious. For it is not the case, as 
they are a very frequent cause of death, and we are sure that we shall 
eventually have to report fatal cases. But we feel that our results plead 
eloquently for the treatment which we have outlined, and appear to 
indicate that the lives of many infected women have been sacrificed by 
too energetic treatment. 

In addition to these somewhat theoretical objections to the employ- 
ment of antiseptics in the treatment of these affections, there is the very 
practical one that they are far from harmless. Any one who is con- 
versant with the literature on the subject will recall the cases of sudden 
collapse following the use of carbolic-acid douches, while the employ- 
ment of bichloride douches is sometimes the direct cause of death. 
Several years ago, the writer did an autopsy upon a woman supposed to 
be dead from puerperal sepsis, but he found all the anatomical lesions 
of bichloride poisoning, and it was at least doubtful whether the sepsis 
or the treatment instituted for its relief had caused her death. 

In looking over the literature after this case, some 46 cases were found 
in which death had followed the employment of bichloride douches during 
the puerperium. In many instances death was clearly due to the employ - 

1 Bumm. Op. cit. 
3 Bumm. Op. cit. 

3 Kronig. Aetiologie und Therapie der puerperal. Endometritis. Cent. f. Gyn., 1S95, 422, 432. 
Discussion uber Endometritis. Verh. de deutschen Ges. f. Gyn., 1895, 498-502. 



622 PATHOLOGY OF THE PUEBPERIUM. 

ment of overlarge quantities of bichloride; but in several cases a single 
injection of several litres of a 1: 4000 bichloride solution resulted in the 
death of the patient from mercurial poisoning. 

When we take these facts into consideration, along with the theoretical 
objections to the employment of antiseptics under these circumstances, 
it would appear that the benefit to be expected from their employment 
is at least very problematical. 

To recapitulate, we would say that in puerperal endometritis, after 
having removed lochia for cultures, the interior of the uterus should be 
explored by the sterile finger, and cleaned out or not according to its 
condition. The uterus should then be douched with several litres of 
boiled water or sterile salt solution. If the bacteriological examination 
shows the presence of streptococci, we should at once desist from all 
further local treatment. If, on the other hand, we have to deal with a 
putrid endometritis, and the symptoms do not yield to the first injec- 
tion, still other injections may be resorted to. If the infection has ex- 
tended beyond the uterus, local treatment should not be persisted in, as 
it will then do more harm than good. 

Bumm 1 pointed out in his article on puerperal endometritis that in 
many instances involution had taken place very incompletely, and he, 
therefore, recommended the employment of ergot to secure better con- 
traction, and thereby occlude to a greater or less degree the lymphatics in 
the uterine wall. My own experience confirms Bumm's 2 statements, and 
I would, therefore, earnestly recommend the employment of the drug in 
cases in which the uterus is larger than it should be at a given period of 
the puerperium. 

In the cases of gonorrhoea! endometritis very little, if any, active treat- 
ment is required at the time, for in the vast majority of cases the slight 
rise of temperature which is noticed at the onset of the disease soon 
falls to normal, and our patients recover spontaneously or are left with 
a chronic endometritis, which can be treated much more advantageously 
at a later period. 

Schucking 3 some years ago recommended the continual irrigation of 
the uterine cavity with antiseptic solutions. His results, however, w r ere 
not appreciably better than those obtained by others who used only the 
intermittent douche, and his methods of treatment never came into very 
widespread employment. With the French, however, the method has 
found warm supporters, and is at the present time employed by Pinard 4 
in almost every case of infection. 

If the method of treatment above outlined does not lead to an amelio- 
ration in the condition of the patient, all local treatment should be 
desisted from, and we should place our reliance upon general tonic treat- 
ment. Our most potent remedies in this regard are strychnine and 
alcohol, and it has been shown by Runge 5 that women in this condition 
can bear much larger quantities of alcohol than when in health. The 
fever should not be treated with antipyretics, and if we feel that it should 

1 Bumm. Histologische Untersuchungen liber diepuerperal. Endometritis. Arch. f. Gyn... 1891, 

2 Bumm. Op. cit. 

3 Schucking. Quoted by Kehrer. Miiller's Handbuch der Geb., 1889, iii. 343. 

4 Pinard and Wallich. Traitement de l'infection puerperale. Paris, 1896. 

6 _Runge. Die Allgemeinbehandlung der Puerperalen Sepsis. Vierte Mittheilung, 1888, xxxiii. 



PUERPERAL INFECTION. 623 

be abated, we may attempt it by the local application of cold, either in 
the form of sponges or cold baths. This method of treatment has been 
enthusiastically advocated by Mace/ Range, 2 and Desternes, 3 and accord- 
ing to them has given very satisfactory results. If the process has 
extended beyond the uterus, and we have to deal with a parametritis or 
a pelvic peritonitis, the application of heat to the lower portion of the 
abdomen, either in the form of poultices or other hot applications, is to 
be recommended. 

Occasionally, surprisingly good results are obtained in cases of pro- 
found septication by the repeated subcutaneous injection of sterile salt 
solution. Attention was first directed to this means of treatment by 
Bosc, 4 and subsequent investigations have in great part justified his pre- 
dictions. 

Of late a great deal has been written on the operative treatment of 
puerperal infection, nearly every prominent obstetrician and gynecologist 
in the country having made some contribution in this direction. Every 
one is agreed as to the advisability of opening parametritic abscesses as 
soon as fluctuation appears, rather than allowing them to rupture spon- 
taneously. In many cases of parametritis we may obtain on palpation 
a semi-fluctuation, which will lead us to suppose that we have to deal 
with pus, but upon opening the supposed abscess through the vagina or 
abdominal wall, as the case may be, we find that our tumor is a mass of 
inflammatory exudate without pus-formation, and only a small amount 
of serous fluid will escape when it is excised. The incision of these 
masses frequently leads to as good results as though we had evacuated a 
considerable quantity of pus, just as we obtain excellent results from free 
incisions in ordinary cases of cellulitis in other portions of the body. 

When we are able to demonstrate the presence of pus tubes or ovarian 
abscesses by bimanual palpation, their removal is urgently indicated, for 
as long as they remain our patient will continue in her septic condition. 

Whether we remove the pus tubes by laparotomy or puncture them 
through the vagina will depend upon their character. If freely mov- 
able, laparotomy should be performed ; while, on the other hand, if 
adherent and readily accessible from the vagina, vaginal puncture 
with subsequent packing of the abscess cavity with gauze is to be pre- 
ferred. 

The operations of which we have just spoken are usually not performed 
until the latter part of the puerperium, because it is not until then that 
definite tumor masses can be made out. 

The chief discussion concerning the operative treatment of puerperal 
infection has been as to the advisability of removing the infected uterus 
at an early period. Here the various observers take quite opposite views, 
the more radical surgeons advocating the early removal of the uterus, 
while the more conservative men do not regard it with great favor. 

It would appear to me that in the vast majority of cases hysterectomy 
in the early stages of puerperal infection is impracticable, for if we oper- 

1 Mace. Traitement de la septicemia pu<§rperale par la refrigeration et en particulier par les bains 
froids. Gaz. des hop., 1894, 1367-1372. 

2 Runge. Op. cit. 

3 Desternes. Indications et role du bain froid dans le traitement de l'infection pu£rp£rale. These 
de Paris, 1895. 

4 Bosc. Injections de serum artificiel dans les maladies infectieuses et les intoxication. Presse 
med., 1896, No. 49, pp. 287-290. 



624 PATHOLOGY OF THE PUERPERIUM. 

ate at a period sufficiently early to prevent the extension of the process 
to other organs, we shall undoubtedly remove a large number of uteri 
unnecessarily; whereas, if we wait until a later period, when other 
organs- have been involved, the operation will likewise be useless. There 
is, however, a restricted field for hysterectomy in puerperal infection, for 
in a certain number of cases we find that the process has not extended 
materially beyond the uterus, but has given rise to abscess formation 
within its walls. In such cases, if more conservative treatment fails, 
we should not hesitate to remove the entire organ. Occasionally in rare 
cases of putrid endometritis nothing that we can do appears to check the 
disease, and in these cases also operation would appear justified. Such 
a case has been reported by Sippel, 1 in which, after the total failure of 
all other methods of treatment, hysterectomy resulted in the cure of the 
patient. 

In a recent article Lusk 2 stated that there is probably a field for hys- 
terectomy in certain cases of uterine thrombosis when infected thrombi 
are carried off to various portions of the body, giving rise to a hectic 
condition. He declares that when this is observed, if the operation be 
done after, say, the second rise of temperature, it offers a very reasonable 
chance of success. No doubt in a small number of cases this may be 
true ; but in the majority of cases the thrombosis has extended far beyond 
the uterus when the pyaemic symptoms make their appearance, and we 
would be obliged to operate through septic tissue. On the whole, the 
question of hysterectomy in this affection seems to depend altogether 
upon our ability to make a correct diagnosis and to foretell the course of 
the disease. This is a matter of great difficulty, and until more accu- 
rate means of diagnosis are at our disposal we do not believe that the 
operation will be very generally accepted. 

The prospects of coping more successfully with puerperal infection 
were greatly brightened in 1895 by Marmorek's 3 announcement that he 
had discovered an antistreptococcic serum. In February of that year 
he stated before the Biological Society of Paris that he was able, by 
growing streptococci in a mixture of human blood-serum and agar, 
and repeatedly inoculating animals with them, so to increase their viru- 
lence as to obtain a culture so virulent that the one-hundred-billionth 
part of a cubic centimetre of it would kill a rabbit in thirty hours. By 
injecting this very virulent culture into immune animals he was able 
to produce what he considered a preventive and curative serum. At 
the same meeting Charrin and Roger 4 stated that they had likewise pre- 
pared a serum by the injection of sterile cultures of streptococci into the 
lower animals, and reported 2 cases of puerperal infection which they 
had successfully treated with it at the Paris Maternity. 

In July, 1895, Marmorek 5 published a long article in the Annates 
de rinstitut Pasteur, in which he described his method of preparing the 
serum, and gave the results of its employment in 413 cases of erysipelas 
and 16 cases of puerperal infection. In all of the latter cases the uterine 

1 Sippel. Supravaginal Amputation des septischen puerperalen Uterus Cent. f. Gyn., 1894, 667-74. 

2 Lusk. Recent Bacteriological Investigations Concerning the Nature of Puerperal Fever. Amer. 
Journ. Obst., 1896, xxxiii. 337-347. 

3 Marmorek. Sur le streptocoque. Comptes rend, de la Soc. de Biol., 1895, x. s£rie, ii. 122. 

* Charrin and Roger. Essai d'application de la s6rum-therapie au treatment de la fievre pu6r- 
perale. Comptes rend, de la Soc. de Biol., 1895, x. serie, ii. 234. 

5 Marmorek. Le streptocoque et le s6rum antistreptoccique. Annales de l'Institut Pasteur. 
1895, IX. 593-620. 



PUERPERAL INFECTION. 625 

lochia were examined bacteriologically, and he found that he had to deal 
with a pure streptococcic infection in 7 cases, all of which recovered. 
When the streptococcus was combined with other organisms the results 
were not so favorable, and 5 of the 9 cases of this character ended 
fatally. Since then antistreptococcic serum has been largely employed 
in all parts of the world in the treatment of puerperal infection, but, as 
far as the writer can see, with very unsatisfactory results. 

In May, 1899, a committee of the American Gynecological Society, 
of which the writer was chairman, made an exhaustive report 1 upon 
this subject, and collected all the cases treated by serum which had been 
reported up to that time, and gave the complete literature upon the sub- 
ject. They found that 352 cases of puerperal infection had been so 
treated, with 73 deaths, a mortality of 20.74 per cent. In a large num- 
ber of cases the lochia were not examined bacteriologically, and there 
was therefore considerable doubt as to whether the infections were due 
to the streptococcus ; but in 101 cases in which its presence was demon- 
strated there were 33 deaths, a mortality of 32.69 per cent. This was 
a very discouraging showing, especially when compared with the results 
obtained by Kronig 2 and the writer without its use, as the former has 
treated 56 and the latter 52 cases of streptococcus endometritis, with a 
mortality of less than 4 per cent. The question therefore arises, Was 
the high mortality attending the use of the antistreptococcic serum 
due to its employment or to other causes? Our investigations indi- 
cated that the antistreptococcic serum was practically harmless, and 
therefore the poor results attending its use could not be attributed to 
its employment. But they can probably be explained in two ways : 
First, that only exceptionally severe cases were treated by it ; and 
secondly, that a large number of the cases so treated were in the 
hands of French observers, who curette the infected uterus as a matter 
of routine, and we have already referred to the serious effect of such 
a procedure. In view of these facts, the committee reported that there 
was no evidence of the curative value of antistreptococcic serum in the 
treatment of puerperal infection ; but at the same time the serum did 
not exert a deleterious effect upon the patient, and therefore might be 
employed if the physician so desired. 

These conclusions stand in marked contrast to the enthusiastic reports 
of many observers, and we are inclined to attribute the good results 
of individual practitioners to the fact that they employed the serum in 
only a few cases, and lost sight of the fact that most cases undergo 
spontaneous cure, if not interfered with. 

It is very difficult to arrive at correct conclusions as to the value 
of therapeutic agents in the treatment of this affection unless large 
numbers of cases are used as a basis, for the reason that its clinical 
course is very variable. It is not at all infrequent, in cases of strepto- 
coccic infection, to see the temperature rise rapidly to 103°-105° F., 
remain there for several days, and then fall as rapidly as it had risen. 
In many cases this occurs without the employment of any treatment, 
and had antistreptococcic serum been employed in such cases it is more 

1 Williams, Pryor, Fry, and Reynolds. The Value of Antistreptococcic Serum in the Treatment 
of Puerperal Infection. Trans. Amer. Gyn. Soc, 1899, xxiv. 80-126. 

2 Kronig. Bakteriologie des Genitalkanales der schwangeren, kreissenden u. puerperalen Frau. 
Leipzig, 1897. 

40 



626 PATHOLOGY OF THE PUERPERIUM. 

than probable that the rapid amelioration of symptoms would have been 
attributed to its use. Such cases illustrate the necessity for extreme 
caution in expressing an opinion as to the value of any method of treat- 
ment, and we consider that correct ideas can only be arrived at by a 
careful and systematic observation of a large number of cases in the 
hands of a single observer 

That none of the methods advocated for the treatment of puerperal 
infection are wholly satisfactory is indicated by the number of methods 
of treatment which have been from time to time advanced, and only a 
few of the more recent methods will be referred to. 

Thus, Fochier 3 advocates in pysemic cases the production of what he 
calls " abscess de fixation " — that is, the production of abscesses on vari- 
ous portions of the body by the subcutaneous injection of turpentine; he 
states that he has observed in numerous cases of pyaemia that the condi- 
tion of the patient improved as soon as abscesses made their appearance 
on the surface, and in his method of treatment he attempts to simulate 
nature. This method has found few followers, and does not give promise 
of any great results. 

Kezmarezky 2 in 1894 reported two cases of severe venous sepsis in 
which he had given intravenous injections of 1 to 5 mg. of sublimate. 
He stated that in both cases a marked effect was apparent, and that both 
recovered. His work was enthusiastically taken up by Rissmann, 3 who 
likewise reported several cures from its employment. But it does not 
appear that this method of treatment will find many imitators. 

Another method of treatment was introduced by Hofbauer 4 in 1896, 
who reported seven cases of puerperal sepsis in which he produced an 
artificial leucocytosis by the employment of nuclein. In some of his 
cases the temperature fell by a lysis and in others by crisis, and he 
believed that the artificial leucocytosis played a marked part in their 
cure. Thus far no one has substantiated his results, but Hirst 5 in a 
recent article states that he believes that more is to be expected from 
this line of treatment than from serum-therapy. 

1 Fochier. Traitement de l'infection puerperale par la provocation de phlegmons sous-cutan£s. 
Ann. de Gyn., 1892, xxvii. 356-362. 

2 Kezmarezkv. Intravenose Sublimatini'eetion (Bacelli) bei venoser Sepsis im Wochenbette. 
Cent. f. Gyn., 1894, 906. 

3 Rissmann. Intravenose Sublimatinjectionen bei Puerperalfleber. Frattenerzt. 1895, i. 240-244. 

4 Hofbauer. Zur Venverthung einer ktinstlichen Leukocvtose bei der Behandlung septischen 
Puerperalprocesse. Cent, f. Gyn., 1896, 441-449. 

5 Hirst. Modern Methods in'the Treatment of Puerperal Infection, and their Comparative Worth. 
Amer. Journ. Obst., 1896, xxxiv. 180-184. 



CHAPTER XXVIII. 

MALFORMATIONS, INJURIES, AND DISEASES OF THE NEW-BORN 

CHILD. 

Malformations. 

Meningocele and Encephalocele. Owing to a congenital opening at some 
part of the skull, some portion of the cranial contents may protrude. The 
defect is most common in the occipital bone, in any portion of which the 
defect may be present, from the peripheral part to the centre. If it 
exists in the anterior portion of the bone, it may extend to the posterior 
fontanelle; if in the back part, it may connect with the foramen magnum. 
The size of the tumor depends, of course, upon the extent of the opening 
in the bone. Similar defects may also be present in the naso-frontal 
region, and less frequently in the basilar^ temporal, and parietal segments 
of the skull. The openings may contain meninges alone, meninges with 
brain matter, or the latter with fluid in the interior; in the latter event 
the anomaly is termed hydrencephalocele. The tumors appear at or soon 
after birth. 

A meningocele is usually small, with little tendency to increase in 
size. It may be more or less pedunculated; it presents fluctuation, but 
no pulsation, and is usually reducible. 

In encephalocele there is distinct pulsation, and efforts at compression 
will be accompanied with evidences of marked cerebral irritation. The 
tumor, though not large, has a wide base, and is partly reducible. 

A hydrencephalocele is apt to be large, lobulated, with sometimes a 
distinct peduncle. Pulsation is usually absent in the tumor, which, 
however, is fluctuating and mostly translucent. Compression is not 
apt to be successful in reducing the tumor. Sometimes there is more 
brain-substance in the tumor than in the cranial cavity, and the infant 
is then microcephalic. 

Prognosis. The prognosis in hydrencephalocele is bad, as the tumor 
usually grows rapidly, and there may be rupture, with immediate death. 
In meningocele and encephalocele the prognosis is better, especially if the 
tumor be small. 

Treatment. Treatment in these cases is of little avail, although the 
withdrawal of fluid and even stimulating injections have been tried. 

Spina Bifida. Owing to congenital failure in the development of the 
vertebral arch, one or more of the laminae may be absent, with resulting 
protrusion of the spinal meninges. The lumbar region of the spinal 
column is the part usually affected. Occasionally, however, we have 
meningocele or encephalocele. (Fig. 322.) The tumor is round, fluct- 
uating, and by compression the cerebro-spinal fluid can be forced back 
into the spinal canal. Too severe pressure, however, may produce eclamp- 
sia or other grave cerebral symptoms. The base of the tumor depends 

(627) 



628 PATHOLOGY OF THE PUERPERIUM. 

upon the size of the opening, being pedunculated if it is small, but more 
sessile if large. The tumor is usually covered with skin, which, how- 
ever, may be absent, exposing the dura mater. If there is not much 
tissue covering the tumor, transudation may occur through the walls, or 
rupture of the sac may take place if growth is rapid. Some portion of 
the lower segment of the cord or the cauda-equina is apt to be imprisoned 
in the sac. The extent of the involvement of nerve-tissue can be meas- 
ured by the paraplegia or other evidences of lesion in the spinal cord and 
nerves. 

Gradual absorption of the fluid may occur, and the child may grow 
up with little inconvenience from the shrivelled tumor. This, of course, 
takes place only when the nerves are not involved. In most cases 
there is a gradual increase in the size of the tumor, with final ulceration 
or rupture, followed by convulsions or coma and death. The fatal ending 
may also come with a gradual emaciation accompanying paraplegia. 

Treatment. The treatment of small tumors consists in the applica- 
tion of a soft compress to avoid friction and to support the parts. When 
the tumor is growing, however, more energetic measures may be tried. 
The simplest procedure is to withdraw the fluid by aspiration, and 
follow this with gentle but constant pressure. The fluid must be slowly 
and cautiously removed, for fear of active nervous disturbance and even 
eclampsia. Injections with iodine of various strengths have been tried, 
but without much success. In some cases the tumor can be surgically 
removed by completely excising the sac. This may be successfully 
accomplished in the pedunculated variety where the opening in the 
lamina is small. It should never be attempted if there is evidence 
that the cord or cauda equina may be involved in the tumor. 

Cyanosis. Xew-born infants sometimes exhibit a persistent blueness 
due to malformation of the heart. This defect usually takes the form of 
deficiency in the inter-auricular and inter-ventricular septa. The great 
vessels may likewise be involved in the malformation, especially the pul- 
monary artery. Dr. J. L. Smith found in over half the cases he exam- 
ined by autopsy that the pulmonary artery was absent, rudimentary, 
impervious, or partially obstructed. He also found the following lesions : 
Eight auriculo-ventricular orifice impervious or contracted ; orifice of the 
pulmonary artery and the right auriculo-ventricular aperture impervious 
or contracted; right ventricle divided into two cavities by a supernumerary 
septum; one auricle and one ventricle; a single auriculo-ventricular open- 
ing, with inter-auricular and inter- ventricular septa incomplete; mitral 
orifice closed or contracted; aorta absent, rudimentary, impervious or par- 
tially obstructed: aortice orific and left auriculo-ventricular orifice imper- 
vious or contracted; aorta and pulmonary artery transposed, the vena 
cava entering the left auricle; pulmonary veins opening into the right 
auricle or into the vena cava or azygos veins; aorta impervious or con- 
tracted above its point of union with the ductus arteriosus; the pulmonary 
artery wholly or in part supplying blood to the descending aorta through 
the ductus arteriosus. 

It is obvious that with any of these grave central lesions, not only the 
peripheral circulation but the nutrition as well must suffer. The blood 
is deficient in oxygen and has an excess of carbon dioxide. The blue- 
ness is most pronounced in the prominent parts of the face, such as the 



IX JURIES OF THE XEW-BOEN CHILD. 629 

eyebrows, cheek-bones, nose, and lips. The hands and fingers are also 
prominently affected. The color varies from a light to a very deep purple, 
the discoloration being* aggravated by crying or other disturbing influence. 

While the infants at birth may be well developed, there are soon 
evidences of failure of nutrition, and they are very susceptible to inter- 
current diseases. The action of the heart is rapid and tumultuous, and 
the respiration is correspondingly disturbed. Various bruits are heard 
upou auscultation of the heart. The infants suffer from lack of suffi- 
cient animal heat, and because of this and pulmonary congestion they 
easily contract pneumonia. Most cases do not survive the first year, 
but if they live longer they present a stunted appearance, with peculiar 
bullous fingers and toes. 

All that can be done in the way of treatment is to strive to maintain 
the natural temperature and a fair nutrition. 

Malformation of the Rectum and Anus. Bodenhamer gives the following 
classification of the congenital defects of these- parts : (1) Congenital nar- 
rowing of the rectum or anus without complete occlusion; (2) complete 
occlusion of the anus by a membranous diaphragm or well-formed skin; 
(3) anus absent and rectum ending in a blind pouch at a point more or 
less distant from the perineum; (4) anus normal in appearance, but 
ending in a cul-de-sac, and the rectum ending in a blind pouch at a 
variable distance above this point; (5) anus absent and the rectum end- 
ing in a fistula opening at any point of the perineal or sacral region; (6) 
the anus absent, and the rectum ending in the vagina, the bladder, or 
the urethra; (7) the anus and rectum normal, but the ureter, vagina, or 
urethra opening into the rectal cavity; (8) the rectum totally absent. 

The time of the passage of the first stool and its size and character 
should always be investigated by the attending physician. Minor degrees 
of stenosis of the rectum or anus are not infrequent in the newly born. 
Although the thin feces of infancy may escape without difficulty, when 
the child grows older and the excreta become more solid, stenosis may 
occasion rnuch inconvenience. 

Treatment. Congenital stenosis is best treated by gradual dilatation. 
A convenient bougie is the index-finger, well oiled, and daily inserted. 

When a thin band of membranous tissue closes the anus, a crucial inci- 
sion will open up the rectal pouch. For the graver forms of malformation, 
elaborate and careful operations are required, which, as they are fully 
treated in works on surgery, will not be considered here. 

Injuries During Birth. 

Excessive Moulding. In difficult labor, even though spontaneously 
completed, the child not infrequently suffers more or less serious injury 
during its passage through the birth-canal. As the head is the part of 
the foetus which normally offers the greatest resistance, it is the most 
frequent seat of such injuries. The soft and yielding character of the 
skull and the moulding to which it is frequently subjected may produce 
marked distortion. The diameter which falls in relation with the axis 
of the birth-canal is elongated at the expense of the engaging diameters. 
The head, however, usually resumes its normal shape within a few days 
after birth. 



63< ) PA THOL OGY OF THE P UERPER1 UM. 

Cephalhematoma is an effusion of blood between the bone and the 
periosteum covering it. It usually appears within one to three days after 
birth. Its seat may be any portion of the cranial vault. Most com- 
monly it occurs in the parietal region, sometimes over the temporal or 
occipital bones. The overlying integument presents no discoloration. 
A bony ring is soon developed around the base. The effusion is, in most 
cases, limited by a suture. The effused blood, as a rule, undergoes absorp- 
tion within the first three months of life. In rare cases suppuration 
ensues, and even caries of the subjacent bone may occur. The fact that 
the tumor does not communicate with the brain cavity, which fact can 
usually be readily made out by palpation, serves to distinguish this affec- 
tion from encephalocele. 

Treatment. In most cases no treatment is called for. Should the 
tumor grow it may be strapped with adhesive plaster, the head first being 
shaved. Incision, while generally condemned, has been practised with 
success. It offers the advantage of immediate relief, and leaves no per- 
manent deformity. The effused blood can usually be removed through 
a small opening. A firm compress is w r orn for several days to prevent 
refilling. It is needless to say that the strictest asepsis must be observed. 
If suppuration occurs the usual surgical treatment of abscess must be 
carried out. 

Injuries to Bone and Muscles. The soft and partially developed con- 
dition of infantile bone renders it liable to injury if subjected to much 
mechanical violence during delivery. The cranial bones are especially 
liable to indentation and fracture when the forceps is employed, yet such 
accidents may occur in spontaneous labor. Fracture of the cranial bones 
is most frequently in the parietals. When the brain is not injured the 
fracture is not apt to result seriously. Rupture of intracranial blood- 
vessels may lead to fatal hemorrhage. Simple indentations apparently 
cause little if any damage to the brain structures. Gentle efforts at 
reduction may be attempted, and thus the normal shape be restored. 
Fracture of the inferior maxillary bone may result from traction with 
the fingers in unskilful delivery of the after-coming head in breech pre- 
sentations. Injuries may be inflicted upon the vertebrae or the spinal 
cord, with resulting paraplegia, and they are almost invariably fatal. 
Fracture of the humerus not uncommonly occurs in forcible delivery of 
the arm in breech births, or separation of the epiphysis from the shaft of 
the bone may take place. Fracture of the clavicle usually results from 
violent use of the fingers in extracting the after-coming head. The 
femur may be fractured from misdirected traction with fingers or fillet 
in breech delivery. Hematoma of the sterno-cleido-mastoid muscle may 
result from artificial interference in breech extractions. A hard tumor 
about the size of a pigeon's egg may be seen developing in this muscle, 
usually on its anterior border. It is noticed between the ages of one 
and six weeks, and usually disappears by absorption in a month or so. 
The muscle fibres are sometimes torn. Hsematoma of the sterno-cleido- 
mastoid may lead to contracture of the injured muscle and torticollis. 

Birth Palsies — Facial Paralysis. Injuries to the nerves during birth 
may be central or peripheral. The former injuries are, fortunately, 
the less frequent. 

Pressure upon the seventh or facial nerve at the stylo-mastoid fora- 



INJURIES OF THE NEW-BORN CHILD. 



631 



men by the blades of the forceps is usually responsible for facial paralysis. 
The affection is, in most cases, unilateral, and will not be noticed when 
the infant is at rest. When nursing or crying the palsy of the affected 
side is apparent. Recovery usually takes place spontaneously in a few 
weeks. If the paralysis does not disappear promptly, faradisni may be 
employed. In rare cases the palsy is permanent. 

Duchenne's Paralysis. The next most frequent peripheral palsy is seen 
in the arm. Various conditions during birth may produce compression 
and injury of the nerves about the shoulder, such as severe pressure of 
the obstetrician's linger or the blunt hook in the axilla, hematoma of the 
sterno-cleido-mastoid, or fracture of the humerus with displacement of 
the fragments. The greatest number of upper-arm paralyses, generally 
known as Erb's or Duchenne's paralysis, occur after breech deliveries. 
The injury usually results from traction made upon the shoulder in the 
delivery of the head, or in bringing down the arm when it is found above 
the head, or upon the head in vertex deliveries, and is due, as a rule, to 



Fig. 362. 




Duchenne's paralysis. (Jewett.) 



Dragging: 



stretching of the fifth, sixth, and seventh cervical nerves 

the head or the trunk strongly to one side is usually responsible for the 

excessive traction upon the nerve trunks of the injured side. The deltoid, 



1 By courtesy of Dr. Wm. H. Haynes. 



632 PA THOL OGY OF THE P UERPERIUM. 

biceps, brachialis anticus, and supinator longus are the muscles oftenest 
affected. In mild cases the paralysis may not be noticed for some weeks, 
while in severe ones it will usually be apparent at once. 

Diagnosis. The position of the arm is characteristic. It hangs 
helpless at the side and is rotated inward (Fig. 362). As the triceps is 
not affected, the child can extend the forearm, but cannot flex it. After 
a few weeks the affected muscles show more or less atrophy, but the 
child will generally begin to use the forearm. The diagnosis of Erb's 
paralysis is not, as a rule, difficult when seen during the first year. The 
peculiar position of the arm and the group of muscles involved are rarely 
met with in any other affection at this early age. 

Prognosis. The prognosis will depend upon the severity of the 
symptoms and the time when the treatment is begun. Spontaneous re- 
covery takes place in some cases within two or three months. If there 
is but little improvement after this length of time, spontaneous recovery 
is not to be expected, and the case demands active treatment. In some 
cases partial paralysis may remain for several years or be permanent. 

Treatment should be begun as early as the third month, and should 
consist in frictions or massage and the persistent use of electricity. If 
the muscles react to the faradic current it may be used; but if not, the 
galvanic current must be employed. The treatment must be continued 
for several months, or until recovery is nearly complete. The foregoing 
treatment applies also in facial paralysis. 

Central Paralysis. A form of meningeal apoplexy, followed by hemi- 
plegia, is one of the results of prolonged and difficult labor. It has been 
supposed that the use of forceps is largely responsible for this accident, 
and the rough and careless use of instruments is doubtless a competent 
cause. The writer believes, however, that too long delay in the applica- 
tion of the forceps when the head is being subjected to prolonged press- 
ure is oftener responsible for this unfortunate accident. The careless 
use of ergot before delivery, by inducing a tetanic contraction of the 
uterus, also favors congestion of the foetal brain. 

Symptoms and Prognosis. The symptoms induced by meningeal 
extravasation depend, of course, upon the seat and extent of the effusion. 
The extravasation is frequently located over the motor convolutions, 
and if not extensive the hemiplegia may disappear with the absorption 
of the blood. If more extensive, however, the infant may be still- 
born, or, if living, it may soon die from asphyxia or in a comatose 
condition. Convulsions may occur shortly after birth, followed by 
coma. If death does not ensue the prognosis for the extremities affected 
is good, as the paralysis gradually improves, often undergoing complete 
recovery. The brain, however, may be irreparably injured, as shown by 
subsequent epilepsy or even by various degrees of idiocy. 

Treatment. The treatment must be preventive. This consists in 
avoiding as much as possible prolonged pressure upon the foetal head, in 
a careful use of the forceps, and in seeing that the infant cries imme- 
diately after birth, thus being assured that the lungs are inflating. It is 
of great importance that the transition from the foetal to the post-natal 
circulation should at once take place at birth, as otherwise great damage 
may be done, particularly to the brain ; the vessels here are fragile and 
easily ruptured. If the infant cries the expanding lungs draw off the 



INJURIES OF THE NEW-BORN CHILD. 



633 



excess of blood that may do damage elsewhere. The physician should 
°ive his first attention to the infant until this happens, as a short period 
>f asphyxia may do incalculable harm. If the lungs do not act, it is 
>vell to let the cord bleed to the extent of a few drachms to prevent 
severe congestion of other vital organs. 

Asphyxia. The accidents during labor that induce asphyxia are: Sud- 
den death of the mother, constant pressure upon the umbilical cord, 
severe compression of any part of the foetal body, especially the head, 
as noted above, and more or less complete detachment of the placenta. 
In consequence of the air-hunger induced by these conditions, a vigorous 
infant may by inspiratory suction take in secretions of the birth-canal, 
which may cause suffocation after birth or induce pneumonia later. Very 
feeble infants may fail to establish respiratory movements after birth, 
owing to weak or defective muscles and nerves. In partial asphyxia 
there is congestion and suffusion of the skin, with blueness of the mucous 
membranes, full pulse, and moderate action of the reflexes. As the 



Fig. 363. 




Byrd's method— expiration. (Jewett.) 

symptoms of carbon-dioxide poisoning become more marked, the pulse 
grows feebler, the skin paler, and the mucous membranes assume a grayish- 
blue color. The reflexes are likewise lost. The prognosis in the latter 
condition is exceedingly bad. In the milder degrees of birth -asphyxia 
recovery usually ensues. 

The Preventive Treatment consists in measures addressed to the 
acceleration of tedious labors and the prevention of prolonged pressure 
upon the foetal parts, especially the head. During descent of the head 



634 



PATHOLOGY OF THE PUERPERIUM. 



malpositions of the cord, especially prolapse, or winding tightly around 
the neck, must be looked for, and, if possible, corrected. One of the 
possible causes of asphyxia will be removed if as soon as the head is 
born it is so turned that the face shall not lie in a pool of blood and 
liquor amnii. At the same time the mouth and fauces can hastily be 
cleaned of mucus with a moist rag drawn over the finger, or by means 
of a soft rubber tube with a rubber bulb attached. In moderate degrees 
of asphyxia the stimulus of the cool external air, and allowing a drachm 
or two of blood to escape by the cord, will be sufficient. Should this 
not suffice the chest may be sprinkled with cold water to stimulate the 
reflexes, while the infant is held suspended by the feet for the purpose of 
allowing mucus to gravitate from the air-passages. The child may be 
plunged alternately into hot and cold water. The hot water should have 
a temperature not exceeding 105° F. When these external stimuli fail to 
excite respiratory movements, resort must be had to artificial respiration. 



Fig. 364. 




Byrd's method— inspiration. (Jewett.j 



The child's pharynx should first be cleared of mucus and other liquid 
material that may have been drawn into it by premature efforts at respi- 
ration. The simplest and most effectual method of inflating the lungs 
is by direct insufflation — the raouth-to-mouth method. 

Direct Insufflation. The child is placed upon its back with the 
head extended by means of a small pillow or roll of clothing placed 



INJURIES OF THE NEW-BORN CHILD. 



635 



under its neck; the month is well cleansed and a towel or handkerchief 
is spread over the face. With one hand closing the nose, and with the 
other making pressure upon the epigastrium, to prevent the inflation of 
the stomach, the physician forces air from his own gently into the child's 
mouth and inflates the lungs. The air is expelled by gentle pressure 
upon its chest, and the process then repeated. When properly per- 
formed, this method is safer than passing a catheter or other instrument 
into the trachea, as is sometimes practised. Care should be taken lest 
injury be done to the air-cells by too forcible expansion. 

Byrd's Method is simple and efficient, and can be conducted without 
rough handling, a matter of no little importance. The child lies upon 
its back on the palmar surfaces of the operator's outstretched hands. 

Fig. 365. 




Schultze's method of artificial respiration— expiration. (Jewett.) 

The operator by elevating the radial edges of his hands doubles the 
child's trunk upon itself — expiration (Fig. 363). Then by lowering the 
radial well below the level of the ulnar borders of the hands the child's 
trunk is thrown into a position of extreme extension — inspiration (Fig. 
364). 

The Method of Schtjltze is as follows : The operator holds the 
infant suspended, face to the front, his index-fingers being hooked in 
the axillae, the thumbs resting on the front of the chest and the fingers 
upon the infant's back. The lower portion of the child's body is 
now swung outward, upward, and finally toward the operator's face, 



636 



PATHOLOGY OF THE PUERPERIUM. 



inverting the position. Care should be taken that the trunk is most 
strongly" flexed in the lumbar region. In this position the thorax 
is compressed — expiration (Fig. 365). The child's lower extremities- 
are now swung outward away from the operator's body and down- 
ward till the child hangs suspended by its axillae in the position first 
described. In this position of the child, hanging by its upper extremi- 
ties, the abdominal contents fall and the diaphragm sinks — inspiration 



Fig. 366. 




Schultze's method— inspiration. (Jetvett.) 



(Fig. 366). To assist the respiratory movements the pressure of the 
operator's thumb is relaxed during inspiration and increased during 
expiration. This method is not to be recommended in feeble children. 
Laborde's Method. Laborde recommends rhythmical traction upon 



INJUBIES OF THE NEW-BORN CHILD. 637 

the tongue eight or ten times a minute as an effective method of estab- 
lishing respiratory movements. It has the advantage that it can be 
carried on while the child is kept in the warm bath, and it does not 
involve rough usage. 

Fig. 367. 




Laborde's forceps for traction on the tongue of the new-born in the treatment of asphyxia. 
(After Ribemont-Dessaignes and Lepage.) 

Other Measures. It must be borne in mind that it is not enough 
that the child begins to breathe: it must be watched for some time to see 
that the respirations continue. It may be advisable in some cases to 
administer hypodernrically ten to twenty drops of whiskey combined 
with 1 minim of tincture of belladonna or y^ grain of strychnine. In 
most cases it will be necessary after resuscitation to apply dry heat 
by a hot-water bag or other means. In asphyxia pallida a rectal injec- 
tion of water at a temperature of 110° F. is of marked service. 

Atelectasis. Closely allied to asphyxia, and often associated with it, is 
a persistence of the foetal condition of the lungs, either of one or both in 
whole or in part. It is due to failure of the infant to completely inflate 
the lungs, and may persist for a considerable time. Sometimes it results 
in death, even after respiration had apparently been fully established. 

This is more apt to involve the lower lobes than the upper ones. It 
is frequently seen in premature infants with feeble respiration. The 
cause may also be injury to the brain from pressure. The symptoms 
are those of deficient respiratory action, such as pallor, feeble cry, and 
poor circulation, with very little expansion of the chest-walls over the 
affected area. Deep inspiration may be encouraged by artificial respira- 
tion, and the vitality conserved by the external application of heat and 
the judicious administration of nourishment and stimulants. 

Foetal Death must be distinguished from asphyxia. In the former 
the heart pulsations cannot be felt, and respirations and reflexes are 
absent. In the latter the heart is pulsating, reflexes are present, and 
there may be feeble attempts at respiration. We should not refrain from 
efforts at resuscitation because the heart-sounds are absent or no pulsa- 
tions can be felt in the precordial region. The distinction between a 
deadborn and a stillborn infant can usually be made by the rapid fall of 
rectal temperature in the former to ten or fifteen degrees below normal 
and by the widely dilated condition of the pupils in the deadborn. One 
or two forcible inflations of the lungs by the mouth-to-mouth method 
will usually cause the heart to pulsate in the stillborn, while it will have 
no effect on the deadborn. If the heart pulsates after this trial, a hypo- 
dermic injection of whiskey, "iv-x, and strychnine, gr. yi^, may be 
given and artificial respiration continued. 



638 PATHOLOGY OF THE PUERPERIUM. 



Diseases of the New-born. 

Mastitis. The mammary glands of the new-born infant often secrete 
a milk-like substance, which appears between the fourth and tenth days 
after birth. During this time there may be swelling of the glands, 
which gradually abates with the subsidence of the secretion until, usually 
by the twentieth day at the latest, both secretion and swelling have disap- 
peared. In some cases, however, the glands may remain eugorged and 
tender, and suppuration ensue. This implies infection, and is exceedingly 
rare when proper antiseptic precautions have been observed during and 
after labor. 

Treatment. When there is simple swelling the parts may be cleansed 
with soap and water and bathed with a weak antiseptic solution, either 
of carbolic acid or bichloride of mercury. Gentle support with absorb- 
ent cotton and a bandage will also be indicated. If, in spite of this, 
suppuration occurs, there will be rise of temperature and the local signs 
of abscess. Then early incision, under proper antiseptic precautions, 
constitutes the treatment. 

Umbilical Hemorrhage. Hemorrhage may take place from the stump 
of the cord shortly after birth, from insecure ligation, from shrinkage 
of the funis, or from slipping of the ligature. Laceration of the cord 
between the abdomen and the ligature may also be responsible for hemor- 
rhage. Secondary hemorrhage, usually between the fifth and fifteenth 
days, may occur, even though the cord has been securely ligated and 
properly watched. The trouble may be due to changes in the walls of 
the minute bloodvessels, allowing transudation, or to imperfect coagula- 
bility of the blood. In the latter case the hypogastric artery and the 
umbilical artery and vein have not been tightly occluded by the usual 
fibrinous plug. The hemorrhage is accounted for by syphilis, jaundice, 
haemophilia, or by depraved health on the part of the parents. 

Treatment. The great majority of cases are fatal from the impos- 
sibility of controlling the hemorrhage. In the milder ones a compress 
of lint tightly applied with adhesive strips may be sufficient. In more 
obstinate cases the lint may be saturated with a styptic, such as MonsePs 
solution. Dr. J. L. Smith recommends filling the umbilicus with a thick 
layer of plaster-of-Paris that is supported by the hand until it hardens, 
and then secured by a bandage. In the most obstinate bleeding the 
umbilicus may be transfixed with two needles placed at right angles, and 
a figure-of-eight ligature be placed tightly around them. 

Umbilical Vegetations. Fungous granulations at times appear, arising 
from the floor of the umbilical fossa, shortly after the falling of the cord. 
They may attain the size of a pea, and they usually exude a bloody serum, 
which may induce excoriations in the surrounding skin. The granula- 
tions may gradually atrophy after weeks or months of sluggish existence. 
The constant moisture and discharge is, however, a source of irritation, 
and it is best to destroy the growths. This can be accomplished by 
repeated cauterization with the solid stick of nitrate of silver, or, better 
still, by passing a ligature around the base of the mass and amputating 
the exuberant granulations with scissors. A dry dressing of boric acid, 
subnitrate of bismuth, or iodoform may then be applied. 

Umbilical Hernia. There may be an incomplete closure of the umbilical 



DISEASES OF THE NEW-BORN CHILD. 639 

ring* from defective development of the abdominal wall, with resulting 
protrusion of abdominal viscera at this point. Tendency to protrusion 
must be corrected at once by the constant application of a pad or truss. 
If this is not sufficient, or if the rupture increases rapidly in size, imme- 
diate operative interference is demanded. 

Icterus Neonatorum. Icterus is a common affection of the new-born. 
Two distinct varieties are recognized, differing widely as regards causa- 
tion and prognosis, and known as the mild and the grave forms. 

Mild Form. Two divergent theories have been advanced to account 
for this form. The first considers the jaundice to be purely haematic; 
the second theory regards it as hepatic in origin. Bile is first formed in 
the liver, and then carried into the circulation, the resorption being due 
either to congestion or to oedema of the hepatic tissue. It seems highly 
probable that both these theories may apply in different instances, and 
doubtless many cases of icterus neonatorum are to be satisfactorily 
explained only by taking into consideration a morbid condition of both 
the blood and the liver, thus combining the haematic and hepatic theories. 

The intense congestion of the skin observed during the first few hours 
of life often produces a yellowish coloration that cannot be considered 
jaundice. It is of the same nature as the discoloration of the skin fol- 
lowing an ordinary cutaneous bruise. The yellow tint is at first seen 
only on deep pressure, but as the erythema fades the yellowness increases. 
The conjunctivae are not colored, and the urine appears normal. This 
yellowness is usually first noticed on the second day, and may continue 
a few days or a week. 

The term " true icterus " can be applied only to those cases in which 
the yellow discoloration of the skin is caused by a staining by the bile 
pigments. This more often occurs in cases of prolonged or difficult 
labor, in children born asphyxiated or before term, and in generally 
feeble infants. It is very frequently seen in foundling asylums. It 
may appear as early as a few hours after birth, but usually is not marked 
until the second or third day. In very mild cases the yellow color 
may appear only on the face, chest, and back, the conjunctivae being but 
faintly tinted and the urine and feces normal in appearance. In severer 
forms the urine may be high-colored enough to stain the linen, and the 
jaundiced hue may extend to the arms and abdomen. Some infants pre- 
sent a yellowish discoloration of the whole body, with typical clay-colored 
stools. In most cases the jaundice has disappeared by the eighth or tenth 
day. It may, however, persist for several weeks. In rare cases, after 
having much diminished, it reappears with renewed intensity. No 
matter how extensive this form of jaundice may be, it causes very little 
constitutional disturbance. The liver may be slightly enlarged, and occa- 
sionally there are symptoms of intestinal catarrh. A few small doses of 
calomel or mercury with chalk will be all the medication required. 

Grave Form. This form is, fortunately, rare, and may be produced 
by several different conditions. Defects in the bile-ducts will first be 
mentioned as among the commonest causes. In some cases all the large 
bile-ducts have been absent; in others the ductus communis choledochus 
has been narrowed, obliterated, or entirely absent. Sometimes a fibrous 
cord has been found in place of the gall-duct. The cystic duct has been 
absent a^id the gall-bladder in a rudimentary condition. Accompany- 



640 PATHOLOGY OF THE PUERPERWM. 

ing an obliteration of the gall-ducts cirrhosis is usually found in the 
liver, which will be more or less marked, according to the length of 
time the infant survives. The liver is generally enlarged. Jaundice 
that is due to obstruction or obliteration of the biliary passages may 
appear a few hours after birth, and soon acquire a marked intensity. It 
often, however, does not appear for one or two weeks after birth. The 
yellowish discoloration of the skin may vary from day to day, at times 
being much more intense than others. The conjunctivae are yellow. The 
fecal discharges lose color and have an offensive odor, while the urine 
stains the napkin a yellow or greenish-brown. The spleen, as well as the 
liver, is usually enlarged, which partially accounts for the increase in 
size of the abdomen. Umbilical hemorrhage is a grave and not infre- 
quent symptom in this form of jaundice. The bleeding is not sudden 
and profuse, but begins as an oozing shortly after the separation of the 
navel string. It is apt to commence at night. Death is always hastened 
by this accident, and exhaustion from loss of blood is added to that 
induced by indigestion and malassimilation. There may also be a species 
of general purpura, bleeding taking place from the nose, mouth, or 
stomach. Infants may live for several months with impervious or 
defective bile-ducts, though death usually takes place earlier, from fail- 
ure of nutrition. 

Another form of grave icterus neonatorum is observed in connection 
with certain inflammatory changes in the liver, usually taking the form 
of an interstitial hepatitis, with which may be conjoined inflammation of 
the biliary canals. This lesion is apt to be one of the results of congen- 
ital syphilis, as is likewise perihepatitis, which may cause a complete 
obliteration of the biliary passages. The latter form of inflammation 
often involves the connective tissue surrounding the common duct, the 
portal vein, and the hepatic artery on the under surface of the liver. 
These cases, however, may not always be of syphilitic origin. Perhaps 
the commonest manifestation of the grave form of icterus in the newly 
born is seen in connection with septic poisoning — that is, generally accom- 
panied with phlebitis. This will be considered under the head of sepsis. 

Umbilical Infection. The umbilicus is the most vulnerable spot for the 
entrance of septic poisons during or shortly after birth. Upon ligation 
of the cord the blood that remains in the umbilical veins forms small 
thrombi that should gradually harden, and in time become calcified, 
forming a fibrous cord in the same manner as in the ductus arteriosus 
and ductus venosus. In these latter structures the formation of thrombi 
is never accompanied with grave consequences, since their internal situa- 
tion prevents the access of infectious agents. Pyogenic organisms, how- 
ever, can readily gain access to the umbilical vein, and give rise to 
umbilical phlebitis and septicaemia. 

There is a constant alteration after birth in the blood-pressure in the 
umbilical vein, due to the action of the heart and lungs, by which a sort 
of flux and reflux is produced. This favors infection of the system 
when the contents of this vein become septic. 

This grave accident is liable to occur when the mother is in a septic 
condition. The poison may be produced by the same agents that have 
caused the puerperal fever. In these cases of sepsis there is a puri- 
form or yellow softening of the thrombi that fill the umbilical vein. 



DISEASES OF THE NEW-BORN CHILD. 641 

The softened matter consists of pus-corpuscles and finely granular matter 
containing micrococci. This sets up an inflammation not only in the 
vessel itself, but also in the surrounding tissues. Infective emboli may 
be carried to various parts of the body. As the micrococci enter the 
umbilical vein from the umbilical fossa, owing to the perviousness of this 
vessel, the structures near at hand, especially the liver, bear the first brunt 
of the septic inflammation. The latter organ is usually found much dis- 
eased or degenerated. There is severe jaundice, with constant elevation 
of temperature and other symptoms of general septic infection. If the 
infant lives long enough peritonitis will probably develop, and sometimes 
empyema or even meningitis. In all cases evidence of severe illness 
and prostration are present. Cutaueous, mucous, or visceral hemorrhages 
may supervene at any time. The abdomen is generally swollen and 
tender, and dirty-looking pus may be seen oozing from the navel; slight 
pressure about the umbilicus will often cause pus to exude if it is not 
otherwise apparent. The fecal discharges may be of natural appearance, 
but the urine is usually highly colored. The infant refuses nourishment, 
and there may be vomiting of greenish matter. Severe nervous symp- 
toms, such as convulsions or coma, supervene before death. While the 
umbilicus is the most common seat of septic infection, any sore or abra- 
sion elsewhere may afford entrance to germs. Erysipelatous eruptions 
on the abdomen, chest, or other parts, are the most frequent manifesta- 
tions of such infection. 

Treatment. The prophylactic treatment of sepsis consists in the 
careful antiseptic management of labor and proper attention and clean- 
liness in reference to the navel. Localized sepsis may be combated by 
the topical use of peroxide of hydrogen, bichloride of mercury solution, 
or other strong antiseptic agents. 

The remedial treatment of systemic infection consists in full stimula- 
tion and general support and the judicious use of external refrigerant 
measures. In the latter condition, however, treatment is generally futile. 

Conjunctivitis. The conjunctival membrane in the newly born is very 
sensitive, and frequently the seat of inflammation. A mild catarrhal 
inflammation is often seen, unattended by swelling of the lids, the inner 
surface being reddened and covered with a slight viscous secretion. The 
eyes must be kept cleansed by frequent bathing or irrigation with a satu- 
rated solution of boric acid. A little vaseline may be applied to the lids 
to prevent retention of the secretion by adhesion of their edges. 

Ophthalmia Neonatorum. This form of purulent conjunctivitis may 
be due to infection by the gonococcus or by various pyogenic cocci. 
The former is the infecting agent in about 36 per cent, of cases. If 
the disease manifests itself by the second or third day, the infection 
probably took place during birth. When there is a delay of a week 
x>r more, however, the virus has probably been conveyed by careless 
attendants, by soiled fingers or other infected objects. The inflammation 
is of an intensely virulent type, involving both the ocular and palpebral 
conjunctivae. The sac is filled with a grayish muco-purulent secretion, 
and there is intense chemosis. The subconjunctival connective tissue 
and skin are much swollen, so that the eye can only with difficulty be 
opened. There are photophobia, pain in the eye, and rise of temperature. 
Unless the symptoms quickly subside, the eye is irreparably damaged 

41 



642 PATHOLOGY OF THE PUERPERIUM. 

by ulceration and partial destruction of the cornea. The inflammation 
begins in one eye, but soon attacks the other unless it is effectively pro- 
tected. 

The Peophylactic Treatment consists in employing antiseptic 
vaginal douches in the parturient woman when there is any muco- 
purulent discharge, and dropping two or three drops of a 2 per cent, 
solution of silver nitrate into each eye immediately after birth, after the 
method proposed by Crede. 

Curative Treatment. When the inflammation has actually begun 
the eye must be kept as free of pus as possible by constant washings with 
a saturated solution of boric acid. The swelled and puffy lids should 
have applied to them every few minutes pledgets of sheet lint that have 
been kept upon a cake of ice, and the pus must be removed every hour 
or two. Constant cleansing and cooling of the surface will require the 
services of a careful nurse night and day. A 2 per cent, solution of 
nitrate of silver, or of bichloride of mercury one or two grains to the 
pint, may be instilled between the lids every two or three hours, accord- 
ing to the severity of the case. As this affection so frequently results in 
blindness, it is well, if possible, to have the advice of an oculist. Pro- 
targol in 10 per cent, solution has been recently recommended as a sub- 
stitute for nitrate of silver. It has the advantage of being less painful, 
and is said to be equally efficient. 

Tetanus Neonatorum. Although this disease is distributed through a 
wide geographical area, it is most apt to be found in filthy surroundings. 
Something beside filth, however, is necessary; there must be a specific 
cause. This consists in the tetanus bacillus, of the pin-head and bristle- 
shaped form. It may exist in straw or dust from hay, which explains 
the fact that horses are subject to tetanus, and that traumatic tetanus is 
often seen among laborers who are employed about farms and stables. 

The disease usually begins during the first ten days of life, and the onset 
is apt to be preceded by great f retf ulness. Disinclination to nurse is soon 
followed by rigidity of the voluntary muscles, usually starting in the 
masseters. The rigidity increases, reaching its maximum in from twelve 
to twenty-four hours. The head is thrown back, and there is a general 
flexion of the extremities. One peculiarity of the disease is that while the 
toes are flexed the great toes are adducted. There may be some relaxa- 
tion at times, especially during sleep, but there are constant exacerbations, 
provoked by any peripheral irritation. Eespiration and circulation may 
be extremely embarrassed, and opisthotonus may be present during these 
exacerbations. 

Treatment. While the specific cause of the disease may gain entrance 
at any point of the body when the necessary lesion exists, the umbilical 
wound is undoubtedly the seat of infection in the great majority of cases 
of tetanus neonatorum; hence the utmost cleanliness must be observed 
in cutting the cord and in dressing it. The scissors, the ligature, and 
the entire management of the navel, cord, stump, and the umbilical 
wound must be rigidly aseptic. The excess of the gelatinous matter 
should be stripped from the cord, and a dry, antiseptic dressing applied. 
Speedy mummification of the stump is the best safeguard against infection. 
Special care must be exercised in the umbilical dressings where the dwell- 
ing is easy of access to stable-yards containing horse-manure or loose earth. 



DISEASES OF THE NEW-BORN CHILD. 643 

When the disease is once established it is almost invariably fatal. In 
cases of suppuration at the umbilicus, frequent cleansing with a solution 
of mercuric bichloride of suitable strength should be employed. With 
reference to drugs, the two most valuable are potassium bromide, gr. iv 
every two to four hours, and chloral hydrate, gr. j every hour. Sul- 
phonal, gr. iij every two hours, by the rectum, has been recommended. 
While these are administered the infant must be given nourishment 
frequently, and stimulants should be freely employed. The difficulty of 
swallowing, however, is a source of embarrassment in satisfactorily car- 
rying out these measures. A tetanus antitoxin is now produced by 
several manufacturing chemists, but so far little experience has been 
reported in the serum treatment of tetanus neonatorum. 

Tubercular Infection. Tuberculosis is very rare in the newly born, and 
is not common in the first year. It has been disputed that the foetus 
can be infected by tubercle bacilli in the uterus, but the evidence seems 
to show that such infection may occasionally, though rarely, take place. 
Acute miliary tuberculosis, however, may develop within the first few 
days of life. In very early life the lymph tracts and bones are espe- 
cially liable to tubercular infection. The prominent symptoms are 
irregular fever, rapid wasting, and prostration. Increased frequency of 
respiration and bronchial rales are present, but the infants usually die 
from a general infiltration of all the organs with fine, miliary tubercles 
before they have time to localize sufficiently in any one organ to be 
detected by physical signs. 

Syphilis. This disease may be acquired from the father or mother, or 
from both parents, the poison being conveyed by the spermatozoa of the 
male or the ovum of the female. While it has been denied by some 
observers that the father alone can transmit syphilis, the consensus of 
opinion is in favor of the possibility of such transmission. Without 
antisyphilitic treatment the spermatozoa can usually convey the syphilitic 
poison during the first year after primary infection, and there is great 
danger to the foetus from syphilitic contagion up to the fourth year. 
The influence of the mother upon the growth and development of the 
foetus contained within her uterus is obviously very great, and when she 
is suffering from constitutional syphilis the disease is transmitted in an 
active stage to her child. The degree of such transmission depends, as 
noted above in the case of the father, upon the stage and severity of the 
disease and the nature of the treatment employed. During periods of 
latency the mother may bear healthy children, followed by abortions or 
syphilitic infants caused by renewed manifestations of the disease. It 
has been considered that the power of transmission is practically lost at 
the end of six years. 

Colles y Law. In 1837 Colles wrote that "A new-born child affected 
with inherited syphilis, even though it may have the specific lesions in 
the mouth, never causes infection of the breast which it sucks if it be 
the mother who nurses it, although continuing capable of infecting a 
strange nurse." The substantial truth of this dictum has not been 
seriously questioned, though various explanations have been offered. 

When the virus of the disease is concentrated, as in cases where both 
parents are syphilitic, the foetus will be attacked by the disease in the 
uterus, and, as a result, abortion will occur more or less early in the 



644 PATHOLOGY OF THE PUERPERIUM. 

pregnancy. As the disease abates in one or both parents the pregnancies 
will be longer in duration, until, at last, apparently healthy infants may 
be born. In some cases the infant will present marked evidences of 
syphilis at birth; often, however, the onset is delayed until later, and at 
birth there may be absolutely no manifestation of the disease. The 
earlier the disease shows itself after birth the graver w T ill be the nature 
of the attack. 

Very early syphilis is usually accompanied by emaciation, eruptions 
of bullae, particularly upon the palms of the hands and soles of the 
feet, and an extreme degree of coryza, cracked and ulcerated lips, and 
evidences of visceral and bone disease. In the older cases there may be 
no interference with nutrition, and possibly one or two mucous patches 
may be the only active evidence of the infection. 

Treatment. The treatment may be local or internal. Daily inunc- 
tions of mercurial ointment mixed with from four to eight times its 
quantity of vaseline or rose ointment are efficacious. It may be rubbed 
on the inside of the thighs or in the axillae, using a portion about the size 
of a hickory-nut. A more cleanly method of local medication consists 
in applying five drops of a 10 per cent, solution of oleate of mercury 
three times daily. Mercury with chalk may be internally administered, 
in doses of \ grain to 1 or 2 grains twice daily. Calomel has a more 
rapid action in doses of from -^V 1° i grain three times a day. Parents 
who exhibit evidence of syphilis or who have had syphilitic children 
should be subjected to full specific treatment. 

Thrush, or Sprue. This is a disease liable to make its appearance during 
the first or second week after the birth of an infant, especially when clean- 
liness of the mouth, bottle, or nipples is neglected. It is a parasitic dis- 
ease, characterized by the appearance of small white patches or flakes on 
the tongue, inside the cheeks, or on the palate. The parasite which 
produces sprue is a fungus consisting of a mycelium network resem- 
bling the moulds and spores. These spores are to be found in the air 
at all times, and they grow in the mouth only in a pathological condition 
of the epithelium, such as catarrhal inflammation or uncleanliness. The 
fungus belongs to the saccharomycetes, or sugar-fermenting organisms. It 
has received the name of saccharomyces albicans, and was formerly known 
as the oidium albicans. When examined with a low-power microscope, 
the white patches are found to consist of small threads and small oval 
spores. With a higher power the threads are shown to be made up of 
small rod-like segments connected together at the ends. From these 
shorter rods the spores are developed. These spores when placed in 
suitable conditions germinate and produce the thread or mycelium. They 
exist in the atmosphere, and when they are deposited upon a mucous 
membrane previously irritated or the subject of catarrh, they grow, pro- 
ducing the patches above described. The growth usually begins at 
many isolated points in the mouth and spreads out into larger patches, 
which often coalesce, forming a more or less continuous membrane. 
Almost the whole of the tongue, cheeks, and hard palate may become 
covered with this membrane. It may even extend to the soft palate and 
pharynx, but rarely into the stomach or intestines. 

Symptoms and Diagnosis. The appearance of the white patches in 
the mouth of the infant, firmly adhering to the membrane, is sufficiently 



DISEASES OF THE NEW-BORN CHILD. 645 

characteristic to make the diagnosis easy and certain. The mucous mem- 
brane of the mouth is usually dry. If the patches be forcibly removed, 
the mucous membrane beneath appears red, and will frequently bleed. 
When these deposits appear upon the tonsils or soft palate they may be 
mistaken for diphtheritic exudate, a mistake which is hardly possible 
if all the symptoms are taken into consideration. The disease is not 
in itself a daDgerous one, and in many cases it should be regarded only 
as a symptom of debility or inanition. 

Treatment. Most important is prophylaxis. Careful attention to 
cleanliness of the mouth, nipples, bottles, clothes, etc., will usually pre- 
vent the occurrence of sprue. The infant's mouth should be carefully 
cleansed several times a day with some mild antiseptic solution, as boric 
acid or sodium salicylate slightly sweetened with glycerin. 

On the first appearance of the white specks or patches in the mouth 
of an infant, it should be washed after each nursing with a 3 per cent, 
solution of hydrogen dioxide, sweetened with glycerin, or a solution of 
sodium benzoate or sodium salicylate, ten grains to the ounce. The 
popular solution of borax and honey is objectionable, since the honey 
feeds the ferment and causes it to grow more rapidly, while the borax 
is not a sufficiently active antiseptic to prevent it. 

The nurse should be cautioned against using harshness in washing the 
mouth, lest she make it sore. No attempt must be made forcibly to 
detach the membrane. If the child is nursed at the breast, the nipples 
should be washed with one of the above antiseptic solutions after each 
nursing; if artificially fed, the rubber nipples must be thoroughly disin- 
fected after using. 

Indigestion and colic are frequent complications of sprue. The pas- 
sages become green and slimy and contain undigested curds and fats. 
It is quite probable that the swallowed ferment leads to acid fermentation 
in the stomach or intestines, with the production of excessive acidity of 
the stools, and frequently the appearance of troublesome erythema of the 
nates. The gastro-intestinal disorder, as well as the primary affection, 
will need careful attention. With proper treatment the disease is easily 
managed. 

Colic. This is a common affection of the new-born infant. The pain 
is usually the result either of flatulence or excessive acidity, due to 
indigestion and acid fermentation. Usually the paroxysms come on at 
certain hours of the day, with intervals of complete or partial freedom 
from pain. It is more prevalent in artificially fed infants than in those 
nursed at the breast. Once established in early infancy it usually con- 
tinues with more or less severity for two or three months. The impor- 
tance, therefore, of careful attention to the food and the feeding of infants 
during their first week becomes self-evident. 

Intestinal fermentation, or decomposition of the food or of the intes- 
tinal mucus, with the production of gas and distention of the bowels, is 
almost uniformly present. This distention and the irritation of the 
mucous membrane by the products of the fermentation induce spasm of 
the muscular fibres of the intestinal walls, which is the immediate cause 
of the pain. 

The most frequent cause of infantile colic is overfeeding during the 
first two or three days after birth, or feeding with improper foods. 



646 PATHOLOGY OF THE PUERPERIUM. 

"When the infant is to be nursed by its mother, no other food should 
be given, unless the mother's milk is manifestly delayed or abnormally 
deficient. If the child is to be artificially fed, no other food should be 
allowed than that prescribed by the attending physician. Milk sugar, 
however, dissolved in water, may be given without harm. In most 
cases the bottle-fed infant is nursed upon the breast for the first week, 
unless deformed or sore nipples prevent. In beginning the artificial 
feeding of infants, nature's method should be followed as nearly as 
possible. During the first three days small quantities only should be 
given. The table on page 287 will serve as a guide to the quantity and 
frequency of meals. 

The cause is occasionally to be found in some abnormality in the quality 
of the mother's milk, the most frequent, during the first and second 
weeks of lactation, being the persistence of a high percentage of proteids, 
which we have seen to be characteristic of colostrum. In such cases the 
infant's stools are usually copious, frequent, and thin in consistency, and 
may or may not contain undigested masses of curd. A microscopic 
examination of the milk will reveal the peculiar corpuscles of colostrum. 
When the fat is excessive, the child will usually vomit after nursing, and 
the stools will contain excess of fat. 

Diagnosis. It must be remembered that crying is not necessarily due 
to colic. Often the cause is need of food. The cry of hunger is usually 
more constant than that of colic, which is intermittent and paroxysmal. 
It is not so violent, the child rather fretting than crying, and is quieted 
by feeding, while the cry of colic is usually rather aggravated than 
relieved by feeding. The pain may be due to other causes than colic. 
There is usually, however, little difficulty in distinguishing between colic 
and other forms of pain. The cry of colic is usually intermittent and 
violent, the child drawing up its knees during the paroxysms, the ab- 
dominal muscles being at the same time tense, and the abdomen usually 
full and tympanitic. Infants who suffer with colic usually appear to be 
hungry most of the time, and, consequently, are often overfed. 

Treatment. The treatment of colic is both palliative and curative. 
It is doubtful if much benefit is derived from carminatives, such as 
anise, fennel, chamomile, gin, etc. 

Better results are secured usually by enemata of warm water or by 
irrigations of the colon, especially when the stools are fetid. A pint of 
warm water injected high up by means of a double soft rubber canula 
may be used as an irrigant twice daily with great benefit. An injection 
of three or four ounces of warm water, with half an ounce of glycerin, 
rarely fails to excite peristalsis with the expulsion of the gas. 

Friction applied to the abdomen, following the course of the colon, 
is sometimes useful. Heat applied by means of warmed dry flannels 
wrapped about the body or legs, or by holding the bare feet near a warm 
stove, is sometimes beneficial. 

The most useful of drug measures is one grain of chloral hydrate 
dissolved in a teaspoonful of anise- water, and given once to three times 
daily. It checks fermentation and quiets the nervous system without dis- 
turbing digestion. Five to ten drops of chloroform-water given every 
hour or two is often efficient in relieving the pains. Milk of asafoetida, 
5j by the mouth, or 5j by the rectum, is a valuable remedy. 



DISEASES OF THE NEW-BORN CHILD. 647 

The curative treatment must be addressed to the digestion. The 
most common cause of the affection in hand-fed infants is overfeeding. 
Xext to this is feeding improper food. Great care is necessary in 
adapting the food to the needs and power of digestion of the new-born 
child. It is well to bear in mind that the most frequent cause of colic, 
as regards the quality of food, is an excess of sugar or casein. An ex- 
cessive amount of fat may, though rarely, be the cause of colic. The use 
of farinaceous foods must be prohibited. If the passages are excessively 
acid aud the nates are erythematous, antifermentatives and antacids are 
indicated. Calomel in one-twentieth -grain doses, with one grain each of 
sodium benzoate and chalk, may be given every two hours. 

The stools must be carefully examined for excessive acidity, fatty acids, 
or fat, and for undigested casein, and the food modified to suit the indi- 
cations here given. White, yellowish-white, or grayish lumps in the 
stools may consist of fat, fatty acids, or casein. Fat and free fatty acids 
dissolve in ether, while casein does not. 

The following paste has been found useful by the author as an 
antacid and antifermentative laxative remedy in the treatment of colic 
attended with constipation : 

Olei ricini gss. 

Magnesii carbonatis ..... <> ... . 3ij. 

Sodii benzoatis . 5ss. 

Sacchari lactis 5ij. 

Olei anisi gttv. — M. 

Sig. Teaspoonful once or twice a day. 

Strict regularity in the quantity and quality of food and frequency 
of feeding and scrupulous cleanliness must be insisted upon. The tem- 
perature of the food is also a matter of importance. If the food be 
given too hot or too cold, it may cause colic. Digestive or nervous dis- 
turbances in the mother, which may cause colic in the nursing infant, 
must receive attention. 



PART VIII. 

OBSTETRIC SURGERY. 



CHAPTER XXIX. 

IMMEDIATE REPAIR OF VAGINAL AND VULVAR LACEEATIONS 
AND OF THE LACERATED CERVIX. 

IMMEDIATE REPAIR OF VAGINAL AND VULVAR LACE- 
RATIONS. 

Without a thorough knowledge of the anatomy and physiology of the 
structures concerned, it is impossible to arrive at a scientific method 
of treating the various injuries to which the vaginal outlet is subjected. 
It must be remembered that the normal outlet of the vagina is not a 
gaping orifice, but in the virgin, as she stands erect, appears externally 
as a mere slit, lying immediately under the vestibule beneath the pelvic 
arch. In a woman who has born children the outlet may be slightly 
relaxed without producing any serious consequences, but all marked 
grades of relaxation must be regarded as pathological. It was formerly 
thought that the wedge of tissue represented by the perineal body, like 
the keystone of an arch, formed the main support of the pelvic contents. 
As a matter of fact, the perineal body in itself has very little to do 
with keeping the organs in position. Again, it has been recently 
demonstrated that the levator ani muscle can hardly possess the func- 
tions assigned to it in this connection, but that the all-important struct- 
ures are the fascial sheets of the pelvic floor. 

On inspection it will be noticed that both the vaginal outlet and the 
anus are situated well forward, the former being under the pubic arch. 
The index finger, when introduced into the vagina, will feel the pubic 
arch above and to the sides, while as it is passed backward it impinges 
upon a resilient band of tissue stretching across the floor of the pelvic 
outlet from one pubic ramus to the other. By making continued firm 
pressure upon the posterior wall of the vagina a marked relaxation of 
this band is produced, together with a definite descent of the pelvic floor, 
which recovers its former position as soon as the pressure is removed. 

The recent work of Browning has shown that the levator ani muscle, 
from its insertion into the perineal body, the external sphincter ani, 
the postrectal raphe and the coccyx, pulls forward and upward the 
post-vaginal structures of the pelvic floor. But the same author has 
shown that in a case examined by him shortly after the expulsion of 
an eight months' foetus there was no evidence of stretching of the fibres 
of this muscle. Again, he argues that it is unphysiologic for a muscle 
to furnish a continuous support. The recto-vesical fascia lies above 

(649) 



650 



OBSTETRIC SURGERY. 



the levator ani and sends processes to the bladder, vagina, and rectum. 
Browning denies that this latter structure is merely a part of the sheath 
of the muscle, and is of the opinion that, when intact, it is sufficient by 



Fig. 368. 




cr. sacrum, b. urethra. 



Dissection of pelvis, from above. (Savage.) 
c. vagina, d. rectum, e. levator ani. /. coccygeus. 



obturator internus. 



itself to afford all the support required to hold up the pelvic contents. 
The recto- vesical fascia consists of the two layers of the triangular liga- 
ment, the superficial fascia and the ischioperineal fascia. Of these, the 
last named is the most important in supporting the pelvic contents. 
A perineal tear that permits gaping always involves these sheets. When 
the ischio-rectal ligament is torn, the pelvic floor sags. But although it 
is possible that the part played by the levator muscle in supporting 
the pelvic contents may have heretofore been exaggerated, it is evident 
that, when it is torn, its restoration as nearly as possible ad integrum 
will always be of the highest importance to the patient, and the condi- 
tion of this muscle should always be taken into consideration in the 
treatment of perineal laceration. 

Character of the Injury. Injuries to the vaginal outlet occur generally 
during parturition. Consider for a moment what happens when a moder- 
ate-sized child comes into the world. Through an orifice which is nor- 
mally from 2 to 3 cm., about an inch, in diameter passes a child's head 
which dilates the outlet until it forms a ring 33 cm., 13 inches, in circum- 



REPAIR OF VAGIXAL AXD VULVAR LACERATIONS. 



651 



Fig. 369. 




Levator ani and coccygeus, seen from 
without, after removal of part of hip bone 
and clearing out of ischiorectal fossa. 
(Luschka.) 

a Fibres of levator ani on vagina, b. 
Anus, with sphincter. 



ference. It is true that this distention when brought about gradually 
and equably by repeated advance and recession of the foetal head may 
be accomplished without injury, but it not infrequently happens that 
the delivery is somewhat precipitate, 
and, instead of gradual stretching, we 
have rupture of muscular fibres or 
fascial attachments. 

The outlet, when compared with the 
capacious vaginal cavity within the 
pelvis, may be likened to the narrow 
vent of a funnel with a wide mouth. 
It would seem surprising that so com- 
paratively small a passage is not more 
frequently injured during the birth of 
the head and shoulders of a child of 
ordinary size. 

Injuries of the vaginal outlet due to 
parturition may be divided into three 
classes : 

1. External or superficial tears. 

2. Internal or combined external 
and internal incomplete tears. 

3. Complete tears. 

1. The superficial external tear be- 
gins at the introitus and extends back- 
ward, involving the superficial portion of the wedge of lax tissue behind 
it. The rupture may extend inward beyond the hymen to the side of 
the posterior vaginal column, which normally lies in close proximity to 
the vaginal outlet, but which during parturition, when the tissues are 
put upon the stretch, is found much further back. 

So long as a tear does not in any way affect' the supporting structures 
the injury done to the outlet is relatively unimportant. A few super- 
ficial stitches are necessary in order that suppuration, granulation, and 
the formation of sensitive scar- tissue may be avoided. (Fig. 370.) Eup- 
ture of the fourchette is the rule, even in normal labors, and need not 
be repaired; but when the tear has a base of 2-3 cm., |— 1^- inch, 
sutures are necessary. The patient should be placed with her body across 
the bed, the buttocks being made to overhang the side ; the legs are 
flexed upon the thighs, and the thighs in turn upon the abdomen, the 
position being maintained by assistants or by means of a leg-holder. 
The labia having been drawn apart, the raw surfaces can be made out 
as two triangular areas separated at their apices, which are formed by 
the divided fourchette, and united at a common base. 

The instruments required are (1) a needle-holder, (2) a small curved 
needle, (3) a few silk or catgut sutures 22 cm. (8 inches) in length. 

The lips of the tear being held apart by the index and second fingers 
of the left hand, the needle is introduced near the upper angle of the 
tear about half a centimeter, ^ inch, from the margin. After having 
been brought out in the bottom of the tear, it is re-entered near this point, 
and emerges on the skin surface on the opposite side at a point corre- 

The next suture having been 



sponding to that of its first entrance. 



652 



OBS 1 'ETRIC S UB GEE Y. 



Fig. 370. 



passed nearer the lower angle of the tear, both are tied, and the wound 
is almost completely closed. Two or three superficial sutures may be 
' required to complete the approximation. During 
convalescence care should be taken not to make 
pressure upon the approximated surfaces with the 
finger or with the nozzle of the syringe, should a 
douche need to be given. The stitches may be re- 
moved about the eighth day. To do this the but- 
tocks- and labia are separated with the fingers and 
thumb, and the surface of the wound is cleansed by 
means of pledgets of cotton saturated with boric acid 
solution ; each suture, being caught in the dressing- 
forceps, is gently pulled forward until the loop is 
exposed, so that it can be cut close to the surface. 
The suture is withdrawn by making traction upon 
the end containing the knot, so that the smooth por- 
tion is drawn through the tissues. 

2. Combined Internal and External Tear. In the 
second form of laceration the injury sustained during 
labor may appear as a gutter-shaped tear, which is 
generally in the median line on the skin surface, but 
within the vagina involves either one or both of the 
lateral sulci of the vagina. The laceration may vary 
in length from 2.5 to 5 cm., 1 to 2 inches, or may be even longer. It 
may be caused by pressure of the head or of the shoulder, the former 




Superficial tear ex- 
posed by fingers parting 
labia minora. 




Superficial combined internal and external tear, showing portion of tear in vagina that may- 
escape notice. 

in its descent producing a tear inside the vagina which may be further 



REPAIR OF VAGIXAL AXD VULVAR LACERATIONS. 



653 



Fig. 372. 




Patient in lithotomy position, on perineal 
pad, ready for the immediate operation. 



enlarged bv the shoulder of the foetus as it forces its way down between 
the levator fibres and their rectal attachments on one or both sides. In 
addition we generally have a super- 
ficial rupture of the fourchette. It 
not infrequently happens that this 
latter portion of the tear is the only 
one attended to, and that the most 
important part, being concealed with- 
in the vagina, escapes notice. (Fig. 
371.) It is, however, the main in- 
jurv to the supports of the vaginal 
outlet which should more especially 
be sought out and remedied. Imme- 
diate repair should be instituted. 
(Fig. 372.) 

Method of Operating-. The 
method of operating for the closure 
of recent internal tears is somewhat 
as follows : The patient should be 
placed in the position just mentioned 
when describing the suturing of a 
superficial laceration ; the perineal 
drainage cushion (Fig. 370) should 
be placed under the buttocks, with the apron over the edge of the bed 
hanging into a bucket. In these cases it is generally better to give an 
anesthetic, unless the patient is confident that she can bear a moderate 
amount of pain. 

The following instruments should be in readiness : 

1. Needle-holder. 

2. Small and medium-sized curved 
needles threaded with carriers. 

3. Six strands of silkworm -gut. 

4. One dozen medium-sized silk or 
catgut sutures. 

5. Emmet's curved scissors, and the 
Sims' or Simon's speculum or a flat 
retractor. An Emmet's needle is by 
some operators preferred to the usual 
surgical needle. (Fig. 374.) 

The anterior wall of the vagina being 
held back and the labia separated by the 
fingers of the left hand (Fig. 370), or by 
means of a speculum or retractor in the hands of an assistant, and the 
upper angles of the wound having been thus exposed, the first suture is 
passed just below the upper angle of the tear, and the next about a centi- 
meter below this, and so on down to the other extremity. The needle 
should be introduced 5 mm. or more from the margin of the wound, 
since otherwise, if there is much contusion of the parts, the suture may 
cut through the weakened tissues. The direction in which the sutures 
are passed is a matter of some importance. The needle should be car- 
ried through the tissues in a direction toward the operator, and brought 



Fig. 373. 




Same as Fig. 367, with internal sutures 
passed, ready to tie. 



654 



OBSTETRIC SURGERY. 



out at the centre of the tear ; it is then re-entered and carried upward 
in a direction away from the operator to the point of exit, which should 



Fig. 374. 




Emmet's needle for suturing the pelvic floor. 



correspond with that of entrance. In this way the approximation will 
be much better than if the sutures are passed in a plane at right angles 



Fig. 




Needle holder. 



to the surface. The part of the suture seen in the floor of the wound 
lies 1 or 2 cm. nearer the perineal angle of the wound than the lateral 
points of entrance and exit. (Figs. 373, 377, 378, 379.) Immediately 



Fig. 376. 




Needle armed with a carrier. 

a suture has been introduced, it should be tied; or the ends maybe 
clamped till all have been laid. 

Xear the vaginal outlet, the tissues being the least yielding just 
where the sutures enter the lateral wall, the part of the suture lying in 
the bottom of the wound is pulled upward. This is what we mean by 
a " lifting suture ; " for it, silkworm-gut softened in sterilized water is 
the best material, being more elastic and smoother than either silk or 
silver wire, and less painful than the latter. On account of its elasticity 
it forms a symmetrical loop in the tissue, so that when the ends are 
brought together the constriction, which is often produced by the sharp 
angular loop made by silver wire, is avoided. Silkworm-gut, owing to 
its smoothness and non-absorbent quality, is not irritating, and sutures 
of this material may be left with safety in the vagina for several weeks. 

To insure success in this operation we must bring about the approxi- 
mation of the torn structures within the vagina, and not onlv those on 



REPAIR OF VAGINAL AXD VULVAR LACERATIONS. 



655 



the skin surface. Two or three sutures introduced as described, with 
the belly of the sutures below the line of entrance and exit, will lift up 
a large tear, and approximate extensive raw surfaces and bring the 
torn edges of the fascia together in a most satisfactory manner. One or 
two superficial or half-deep sutures of fine silk on the skin surface will 
then complete the approximation. If, instead of adopting the method 
just outlined, all the sutures be passed from the skin surface in what 



Fig. 377. 



Fig. 378. 




Internal stitches in position 



Internal stitches tied. 



would at first sight appear to be the natural curve beneath the lacerated 
tissue, it is only too probable that the really important part of the tear 
— viz., that within the vagina — will be left ununited. In this way a 
pocket is formed in the vaginal wall, in which secretions may collect, so 
that any attempt at union will be frustrated, and a troublesome perineo- 
vaginal fistula may even occur. In any case, although there may be 
good external union and the skin perineum be perfect, a relaxed outlet 
will surely be left. 

After-treatment. After the patient has been put to bed it will 
seldom be necessary to bind her legs together or make her keep strictly 
in the dorsal position. She may be allowed to turn slowly in bed, or 
even to elevate the knees, provided only that she keeps them together. 

Catheterization may be necessary at intervals for the first day or two, 
on account of ischuria or retention, but the patient should always be 
encouraged to pass her urine voluntarily if possible. The bowels should 
be moved, after twenty-four hours, with citrate of magnesium or Rochelle 
salt given by the mouth. If there be straining at stool, the index finger 



656 



OBSTETRIC SURGERY. 



should be anointed and introduced into the rectum for the purpose of 
removing any scybalous masses that may be present. After the urine 



Fig, 




Internal stitches tied ; external stitches in position. 



Fig. 380. 



has been passed the labia should be separated and 2 grams (3ss) of iodo- 
form and boric acid powder (1 : 7) may be 
dusted upon the wound. A pad of absorbent 
cotton is then applied, and held in place by a 
T-bandage. The sutures may be removed in 
from eight to ten days after the operation. The 
patient should be kept in bed from twelve to 
fourteen days, and should not be allowed to 
exert herself much for four or five weeks. 

3. Complete Tear. The third form of re- 
cent tear involving the rectum starts at the 
fourchette and extends back in the median 
line of the perineum through the sphincter 
ani, and to a variable extent involves the 
recto-vaginal septum. (Figs. 380, 381.) It 
must be remembered that the external tear 
occurs in the median line, while the internal 
rupture is always lateral, occurring on one 
or both sides. The function of the external 
sphincter muscle, when its fibres have been 
torn through, is lost, and as a result we may have incontinence of fseces 
and flatus. Yet such patients will often put off an operation for months 




Sagittal section of posterior vagi- 
nal wall, perineum, and rectum. 
The area embraced by ou rep- 
resents an outside, more or less 
superficial tear. The area above 
in represents a tear more on the 
inside of the vagina, and the area 
outside of so includes the whole 
skin perineum and sphincter ani. 



REPAIR OF VAGINAL AND VULVAR LACERATIONS. 



657 



or years, until their condition is unbearable. An immediate operation is 
advisable in these cases, since, if it is successful, the patient will be 
spared much discomfort and misery. She saves time and the greater 
annoyance and suifering incident to a secondary operation. Again, 
immediately after labor there is less tension of the torn structures, 
owing to loss of muscle-tone. 

Method of Operating. The woman should be placed in the lithot- 
omy position, as described above. The complex tear is first reduced to a 
simple one, by closing the rent in the bowel, which is a very important 
part of the injury. (Fig. 382.) Beginning at the apex of the tear, a 
series of interrupted catgut or silk sutures is. inserted. Buried catgut 
sutures may advantageously be employed for this purpose. The first 

Fig. 381. 




Complete tear, involving the recto-vaginal septum. 

suture is introduced on the rectal side of the rupture, and it penetrates 
the tissues of the septum deeply enough (5 mm.) to ensure a firm 
hold. One turn of the first knot and two of the second will make it 
hold securely. The remaining sutures are passed in a similar manner 
until the ruptured sphincter is reached. It is not unusual to find that 
on one or both sides the torn ends of the sphincter have retracted, 
leaving a pocket. It is of the utmost importance that this condition 
be rectified ; the ends of the muscle must be sought out carefully and 
brought into accurate approximation. A tenaculum may be employed 
to draw out an end of the retracted muscle, which is then secured by 
means of one or two catgut sutures passed through it. The other end 
having been caught, the sutures are passed through it and pulled tight, 

42 



658 



OBSTETRIC SURGERY. 



tied, and buried. To relieve undue tension upon these approximation 
sutures it is advisable to employ one or two silkworm-gut sutures, which 



Fig. 382. 



Fig. 383. 





Complete tear ; closing the rent in the bowel. 



Deep interrupted lifting sutures in position. 



are made to enter and emerge in the muscle farther away from the torn 
ends and circle about 1-J- centimeters above the angle of the tear up to 
the recto- vaginal septum. 



Fig. 384. 



Fig. 385. 





All sutures laid; vaginal sutures tied. 



Internal and external sutures tied. 



After eliminating the rectal complication, we have left a tear such as 
has been described, involving the fourchette and usually extending a 



REPAIR OF VAGINAL AND VULVAR LACERATIONS. 659 

short distance upward in the median line, or into one or both sulci of 
the vagina. This part of the wound is closed by deep interrupted lift- 
ing sutures in the manner detailed when speaking of the second form 
of laceration. (Fig. 383.) After these sutures have been tied, it is 
advisable to employ a few superficial silk sutures to complete the 
approximation. (Figs. 384, 385.) To have union throughout, perfect 
approximation is necessary, and it is essential that the sutures be prop- 
erly laid. In very deep lacerations it is sometimes advisable to use tiers 
of sutures, the first suture consisting of a running catgut suture laid in 
a plane near the bottom of the wound, and the next at a slightly higher 
level. The last tier may consist of interrupted silkworm-gut sutures, 
which are tied on the vaginal surface. An operation such as has been 
described will generally restore the relaxed outlet almost to its normal 
condition, if the parturient period has been properly conducted, so that 
puerperal sepsis is prevented. The repair may be postponed, and in 
some cases this has to be done, but only by an early operation can the 
parts be restored to their primitive integrity. All secondary opera- 
tions are less efficacious. 

After-treatment. The after-treatment is to be conducted in ac- 
cordance with the general principles laid down elsewhere. The same 
rules as to the evacuation of the bladder and the bowels advised before 
and after other operations must be carefully carried out. Catheters can 
be sterilized by boiling for five minutes in a 1 per cent, soda solution. 
This procedure, however, is very deleterious to the ordinary rubber or 
gutta-percha catheter, and for this reason glass catheters are invalu- 
able. Though they are sometimes broken in the boiling, this is of 
no great moment, as they are cheap, and by their use greater safety is 
insured. 

In ordinary instances the nurse may be allowed to give the enema, 
but in cases of complete laceration the physician should take this duty 
upon himself. The index finger, smeared with vaseline, should be 
gently introduced into the rectum, in order to determine the exact 
direction of the canal ; with this as a guide the syringe is carefully 
inserted and the injection is given slowly. This caution is not super- 
fluous. More than once the point of the syringe has been thrust between 
the stitches passed through the perineum. One case is reported in which 
it was pushed through the coat of the bowel, and a laxative enema was 
forced into the pelvic cellular tissue. The patient died from the exten- 
sive sloughing which followed. 

Straining during the act of defecation must be avoided, and hard 
masses of feces in the rectum must be removed by the finger of the 
physician. In doing this, pressure should be made toward the sacrum. 
As a rule, a vaginal douche is unnecessary. If the discharge is foul, 
but the patient has no fever, one consisting of a saturated solution of 
boric acid or of a 2 per cent, solution of carbolic acid may be employed, 
and if this procedure is followed by no improvement, the uterine cav- 
ity should be carefully explored and, if necessary, curetted. 

A pad of absorbent cotton is applied loosely over the vulva ; it is at 
first changed every two or three hours, and later three times daily. 

All perineal cases must be kept in bed for two weeks ; on the eighth 
day the external sutures are removed. The silkworm-gut sutures should 



660 OBSTETRIC SURGERY. 

be pulled out so that the wound surfaces are drawn together, rather 
than apart. The internal sutures can be removed at the end of two or 
three weeks. 



IMMEDIATE REPAIR OF THE LACERATED CERVIX. 

The primary operation for this condition is only rarely indicated. It 
is impossible for labor to take place without more or less extensive rupt- 
ure of the cervical tissues, but even in cases of severe laceration, it 
has generally been thought better, as a rule, to remedy any defect later, 
rather than add to the severe trials of the woman at the time of 
labor by immediate operation. In instances of persistent hemorrhage 
from the circular artery, however, it may be necessary for the safety 
of the patient to repair the lacerated structures at once in order to stop 
the bleeding, and not a few cases are quoted in which life has apparently 
been saved by resort to this procedure. The most recent literature 
upon the subject shows an increasing tendency to undertake the immedi- 
ate operation in less severe cases also, and when we consider the later 
dangers of a lacerated cervix to the patient and the natural repugn- 
ance that exists in many cases to the secondary operation, together with 
the serious consequences resulting from the neglected cervical injuries, 
the question arises whether it is not better to unite at once the raw 
surfaces and thus effect two purposes at once : (1) the closing of avenues 
by which infective material may enter, and (2) the ayoidance of inju- 
rious results which may follow from the neglect to rectify the condition 
later. It is true that the tumefaction of the tissues may make it diffi- 
cult to secure proper coaptation, but with a little care any objection to 
the procedure on this score may be overcome. 

Method of Operating. The operation itself is comparatively 
simple. With the patient in the lithotomy position, the cervix is drawn 
down and held in position by means of a tenaculum or a volsella, and 
stitches are of about one inch apart from above downward. As care- 
ful approximation as possible should be obtained, a result which may be 
promoted, if necessary, by a few superficial stitches. A teaspoonful of 
iodoform and boric acid powder (1 : 7) may be dusted over the wound. 
The stitches may be removed about the twenty-first day. 



CHAPTEE XXX. 

THE INDUCTION OF ABORTION AND OF PREMATURE LABOR. 

Definition. Before dealing with the various means at our disposal for 
the artificial emptying of the uterus before term, it is necessary to dis- 
cuss briefly the significance of some of the numerous terms which have 
been applied to the interruption of pregnancy. Zweifel distinguishes 
two main classes of cases : (1) those in which the ovum is usually dis- 
charged in toto, and (2) those in which the fetus is extruded after rupt- 
ure of the membranes. Thus, he would apply the term abortion to 
expulsion of the ovum before the end of the sixteenth week, and that 
of premature labor to its expulsion between the beginning of the seven- 
teenth week and full term. Although much can be said from an 
anatomical standpoint in favor of this classification, the fact remains 
that when operative interference is indicated the question whether we 
are dealing with a viable or a non-viable child is often of predomi- 
nating importance as regards the selection of the method to be em- 
ployed. For our present purpose, therefore, it will be more convenient 
to adopt a different division, and to consider abortion as a delivery of 
the fetus before it is viable — i e., before the end of the twenty-eighth 
week ; while the discharge of the uterine contents between this time 
and full term will be spoken of as premature labor. 

Mention has already been made in another chapter of cases in which the 
exciting cause of abortion or of premature labor has been beyond our 
reach ; but a very important class still remains, namely, those instances 
in which the physician himself, for good cause, finds it necessary to 
bring about the premature discharge of the contents of the pregnant 
uterus. 

The induction of abortion or of premature labor in non-pathological 
conditions is rightly regarded in civilized communities as a moral and 
civil crime, and one to be punished with severe legal penalties. 
Although, therefore, it is generally agreed that medical science may on 
rare occasions be above the law, it is evident that it must always be the 
first duty of the physician to place both his patient and himself beyond 
the imputation of any intention to commit a serious crime. There 
should be no false modesty or concealment about the operation. Inten- 
tional secrecy may, unjustly, be looked upon as prima facie evidence 
of criminality. When, however, the mother is in such physical con- 
dition that further continuance of gestation would be perilous to her 
life, it is generally conceded that interference with pregnancy is not 
only justifiable, but a solemn duty. But so serious a course should 
never be decided upon by one physician alone. To demonstrate abso- 
lutely the absence of criminal intent should be his first thought. This 
end may be best accomplished by calling in consultation a colleague, 

( 661 ) 



662 OBSTETRIC SURGERY. 

and not proceeding to operation until the necessity for it has been care- 
fully demonstrated, a full explanation of the circumstances of the case 
has been made to the members of the family more directly concerned, 
and the course to be pursued has met with their full approval. 

The first point to be considered in deciding whether an interference 
with gestation is necessary is the physical and mental condition of the 
mother. Should it seem to the physician, after careful thought and 
consideration of the particular case, that the woman's life will be 
seriously threatened by allowing the pregnancy to continue to term, the 
next question to be decided is, whether it may not be possible to wait 
until there will exist some chance for saving the life of the infant as 
well ; in other words, whether we ought to bring about an abortion or 
a premature labor. 

Indications. Among the conditions in which interference with gesta- 
tion may be justifiable are the following : 

1. Death of the fcetus in utero. 

2. Grave pathological conditions of the viscera, such as advanced 
cardiac disease, phthisis which is clearly making rapid progress on 
account of the pregnant condition, kidney lesions threatening eclampsia, 
and persistent and advancing jaundice. An acute nephritis is especially 
dangerous when it occurs during pregnancy, and experience has shown 
that the emptying of the uterus has often cut short the process. 

3. In the vomiting of pregnancy which has resisted all other 
measures, and where the patient's strength is rapidly failing, the induc- 
tion of abortion may be necessary as a last resort. Still, it is only 
right to wait as long as we dare, and sometimes to give the stomach 
long intervals of entire rest, the strength of the patient being partially 
supported meanwhile by nutrient enemata. The various surgical pro- 
cedures which have been tried are very rarely of any use in these cases. 
Occasionally applications to the cervix have appeared to be beneficial, 
and Martin states that dilatation in his hands has been successful ; yet 
Runge holds that this method is absolutely unreliable. 

4. Certain diseases of the blood and of the nervous system — e. g., 
pernicious anemia, leucocythaeniia, acute melancholia, acute mania, and 
inflammatory affections of the brain — apparently depending upon the 
pregnancy or increased by it. In pernicious anaemia Bischoff prefers the 
induction of premature labor, and denies that abortion is necessary ; he 
argues that anaemia becomes dangerous only during the latter half of 
pregnancy. 

5. Where the mechanical conditions are such that the birth of a 
viable child becomes an impossibility ; for example, in cases of retro- 
flexion of the gravid uterus with incarceration below the superior strait, 
or an abnormally small calibre of the vagina such as would prevent the 
passage of the child. Again, the presence of benign or malignant 
tumors which would effectually preclude delivery of a child at term 
through the natural passages, and hernia of the uterus resisting all 
other treatment bring up the question of the advisability of putting an 
end to the pregnancy. 

When the uterus is retroflexed and incarcerated, and when all at- 
tempts, even under narcosis, to raise it above the superior strait have 
proved ineffectual, the indication for abortion is absolute. Except in 



INDUCTION OF ABORTION AND OF PREMATURE LABOR. 663 

these cases, however, it is always the duty of the attending physician 
to weigh carefully the question how long it may be safe to delay empty- 
ing the uterus ; and if it be possible, without grave risk to the mother, 
to wait until there is a chance of securing a living child, interference 
in the later stages of pregnancy should be preferred. Under some cir- 
cumstances in cases of narrowing of the vagina, where the smallness 
of the calibre is due to cicatrices, lateral incisions or other operations 
may be indicated. In cases of obstruction, from whatever cause they 
may arise, the question of Cesarean section with its various modifica- 
tions should always be taken into consideration. 

Methods of Inducing Abortion. 

The mechanism of the premature discharge of the contents of the 
pregnant uterus resembles in the main that of normal labor. In bring- 
ing about the expulsion by artificial methods we should, as far as pos- 
sible, imitate nature, the essential element in the operation being to 
secure contractions of the uterus and the consequent evacuation of the 
organ. The process is really a reflex act, implying the application of a 
stimulus and a conveyance of it to nerve-centers, from which an impulse 
is sent down to the peripheral nerves which causes the uterus to contract. 

Such a reflex act may be brought about in various ways, and the seat 
of the original stimulus need not of necessity be the uterus itself. It 
has long been known that irritation applied to the breasts, and more 
especially to the nipples, is often followed by uterine contractions of 
greater or less intensity. This fact has been taken advantage of by 
Scanzoni, Avho has formulated a method of inducing abortion by irrita- 
tion of the nipples. But, as might be expected, the strongest and most 
effectual contractions can be brought about by the application of the 
stimulus directly to the interior of the uterus. 

Stimuli may be distinguished as (1) chemical, (2) mechanical, (3) 
thermic, (4) electrical. An accurate classification along these lines, 
liowever, presents great difficulties, since some stimuli may act in more 
than one way. For instance, drugs may have a chemical and a 
mechanical effect and hot water injections may act as a mechanical as 
well as a thermic stimulus. For practical purposes stimuli may be 
conveniently discussed in three main classes : (1) Drug stimuli. (2) 
Stimuli applied to some region other than the interior of the cervical 
canal or the uterine cavity. (3) Stimuli applied directly to the interior 
(a) of the uterine cavity or (b) of the cervical canal. 

1. Drugs. Many drugs have been employed for the purpose. 
Among the chief of these so-called ecbolics are ergot, cotton-root-bark, 
quinine, pilocarpine, the smut of Indian corn (ustilago maidis), and 
various essential oils, especially those of savine, rue, parsley, tansy, 
and pennyroyal. Of all these the most effective is undoubtedly ergot, 
which is capable of bringing on, as well as of strengthening, uterine 
contractions. But the contractions excited by ergot have a tonic char- 
acter in contradistinction to the normal clonic or recurrent contractions 
which it should be our aim to secure. Thus, even when given in quite 
large doses, it often fails to accomplish fully the object in view, and 
•operative interference may become necessary to complete the evacuation 



664 



OBSTETRIC SURGERY. 



of the uterus. Of the other drugs of this class, it may be said that 
their action is even more uncertain than that of ergot, and the exhi- 
bition of them in doses sufficient to cause abortion is always accompanied 
by considerable risk and even danger to the life of the patient. Oil of 
tansy and oil of rue are much relied on by the laity for the production of 
abortion, and almost every day one may read of fatal results attending 
their use. Oil of tansy in large doses is said to excite epileptiform 
convulsions ; quite recently one of my colleagues met such a case in his 
practice. 

Abortion has been brought about by reflex stimulation of the 
uterus through free purgation. Magnesium sulphate in heroic doses 
has not infrequently been used for this purpose. Its action, however, 
is quite uncertain, and nothing can be said in favor of this method. It 



Fig 




Field of operation and the neighboring parts protected by gauze diaphragm, towel and stockings. 



is probable that the irritant purgatives have much more effect, but their 
use in sufficient doses is highly dangerous. It is more than possible 
that oil of tansy and oil of rue act in this way. In brief, it may be 
said that the employment of drugs for bringing about the evacuation of 
the uterus should be entirely discarded. Their action is uncertain and 
slow, and in effective doses their use is always accompanied with 
danger. 



INDUCTION OF ABORTION AND OF PREMATURE LABOR. 665 

2. Scanzoni's method, which consists in massage or rubbing of the 
nipples, is uncertain in its action and sometimes exceedingly painful to 
the patient. It is not to be recommended. 

Tamponade of the vagina is very effective in some cases, and, as has 
been said, is often employed in cases of inevitable abortion to stop the 
hemorrhage and to bring about dilatation of the cervix and contractions 
of the uterus. The tampons may be made of gauze or cotton, or the 
colpeurynter more especially recommended by C. Braun may be em- 
ployed. The external parts having been carefully disinfected, the 
vagina is first rendered as aseptic as possible by flushing with several 
douches ; it is then washed with soap and water, a cotton sponge being 
used, and afterward with a 2 per cent, solution of creolin, followed by 
a 1 : 1000 solution of mercuric chloride. After having been finally 
irrigated with an abundance of normal salt solution, it is dried with 
small pledgets of aseptic absorbent cotton. In the further steps of the 
procedure it is advisable to employ a sterilized gauze perineal apron, 
the operator working through a slit in it which corresponds to the 
vulvar opening. Two or three tampons of sterile absorbent cotton, or 
of 10 per cent, iodoformized or plain sterile gauze, are then introduced 
on either side of the cervix, and are held in position for several minutes, 
moderate pressure being employed. After this a fresh tampon is in- 
troduced, which is followed by others until the vagina is completely 
filled. (Fig. 386.) Dry tampons stay in place much better than 
those which have been soaked in disinfectant solutions, and are quite as 
efficient. In the place of these tampons the colpeurynter may be 
employed. (Fig. 387.) The tampons or colpeurynter should not be 
allowed to remain in position more than 
twenty-four hours. After their removal a FlG - 387 - 

2 per cent, solution of carbolic acid may 
be employed as a douche. In view of the 
fact that in susceptible patients poisoning 
has been sometimes produced by carbolic 
acid, many authorities prefer to use sterile 
normal salt solution. If the first tam- 
ponade does not produce the desired effect, 
a second or even a third may be employed. colpeurynter. 

The method is usually effective, but it has 

the disadvantage that it is almost always slow and not infrequently 
painful. 

Kiwiseh's method consists in the injection of warm water against the 
cervix. He recommends the use of a fountain syringe and water at a 
temperature of about 42.5° C. (106° F.). The douche is given two or 
three times daily for fifteen minutes at a time, the stream being directed 
against the cervix. Care must be taken not to inject air into the 
cervical canal. The heat of the water and the force of the stream are 
important factors in this method, which, although slow, is often effective. 

Electricity. The use of the galvanic current has been strongly rec- 
ommended by some authors. The positive pole is applied over the 
sacral region or over the lumbar vertebra?, and the negative pole is 
applied to the exterior of the cervix in the posterior cul-de-sac. The 
method has not, as yet, been much employed. 




66(3 OBSTETRIC SURGERY. 

3. (a) Krause's method consists in introducing a flexible elastic 
bougie between the wall of the uterus and the membranes. The proced- 
ure has been modified in various ways. Some authorities allow the 
instrument to remain in place from twelve to twenty-four hours, while 
others hold that it should be introduced and then immediately with- 
drawn. Bougies are preferable to catheters, since in the employment 
of the latter there is danger of introducing air into the uterine sinuses. 
The instrument must be soft and flexible, otherwise there is great risk 
of perforating the amniotic sac, or even the uterine wall itself. Steel 
sounds should not be employed. Strict asepsis of the external genitals 
and vagina and of the hands of the operator and his assistants is to be 
observed. 

The procedure may be carried out as follows : The cervix being 
thoroughly exposed, the bougie is pushed gently in until the tip lies 
near the fundus. After being allowed to remain for several minutes it 
is withdrawn, and the vaginal canal is packed with tampons ; or the 
bougie may be left in situ and the tamponade of gauze be made around 
it. Should there be much hemorrhage, evidenced by blood flowing 
down along the bougie, so that we have reason to suspect that the placen- 
tal site has been invaded, the bougie should be withdrawn and reinserted 
in another direction. The hemorrhage will then probably cease spon- 
taneously. If, however, it becomes alarming, a firm vaginal tamponade 
may be made, or preferably a colpeurynter may be inserted into the 
vagina close up to the cervix and allowed to remain for some hours, 
unless indications for its removal should appear. This method is not 
to be recommended during the first two or three months, but in the 
later stages of pregnancy it is one of the most satisfactory which we 
possess. It usually acts promptly and effectively. The operation in a 
crude form is often resorted to by women in order to free themselves 
from the consequences of pregnancy, frequently with disastrous re- 
sults, which are due almost always to infection following a total lack 
of asepsis. It is also in vogue among the unsavory class of men and 
women known in communities as " abortionists." 

Hamilton' s method consists in the circular detachment by means of 
the finger of the foetal membranes for a short distance above the internal 
os. The employment of this method presupposes a dilatation of the 
cervical canal so that it is capable of admitting a finger. Its action is 
similar to that of Tarnier's method, but is not so certain. 

Tarnier's method consists in the insertion of a dilatable rubber bag 
into the cervical canal and extending slightly above the internal os. 
The distention of this bag with water, and the subsequent separation of 
the membranes from the decidua for a certain distance above the inter- 
nal os, excite uterine contractions, with a coincident dilatation of the 
cervix. Except that in Tarnier's method the bag is inserted somewhat 
higher up, the procedure differs in no essential respect from that of Barnes. 

The advantages of' this method consist in the preservation of the bag 
of waters, and in the simultaneous induction of uterine contractions 
and of dilatation of the cervix. 

In using any of these rubber bags it is necessary that the material 
be new and be well preserved, otherwise they will be very apt to rupt- 
ure when distended and thus allow a quantity of water to get into the 



IXDUCTIOX OF ABORTIOX AXD OF PREMATURE LABOR. 667 

uterus. They should be rendered thoroughly aseptic, both inside and 
outside, before being employed, and the water used for filling them 

Fig. 388. 




Barnes' bag. 



should previously have been boiled, so that if rupture takes place no 
great harm may be done. This method usually acts quickly and 



Fig. 389. 




McLean's bag. 

thoroughly, and is especially to be recommended in pregnancies be- 

FlG. 390. 




Tarnier's uterine dilator. 



tween the third and the end of the sixth month. (Figs. 388, 389, 390, 
and 391.) 

Cohen's method consists in the injection of fluids between the mem- 
branes and the uterine wall. No special apparatus is necessary, since 
one which will serve all purposes can readily be improvised. The 
nozzle of the syringe or douche bag should be from -g- to J inch, 0.31- 
0.62 cm., in diameter, and from 6 to 8 inches, 15-20 cm., in length. 
It is better to employ a sterilized piston-syringe, which will admit of 
the injection being made more gradually. The nozzle should be intro- 
duced carefully and the fluid injected slowly, so that rupture of the 
membrane may be avoided. From 1 to 3 ounces, 30-90 cc, of the 
sterile solution will probably be sufficient. The apex of the nozzle 
should be passed about two inches, 5 cm., up the cervix beyond the 
external os. The distance will, of course, vary according to the dura- 
tion of pregnancy and consequent size of the uterus. All air must be 



668 OBSTETRIC SURGERY. 

expelled from the apparatus before the insertion of the nozzle. ^ Should 
the desired effect not follow in the course of six hours, the injection may 



Fig. 391. 




Tarnier's uterine dilator in situ : the bag is round in shape, but is compressed by the intra- 
uterine tension. 

be repeated. The method is not to be recommended. Septic infection 
has often been observed, much more frequently than after employment 
of the majority of the other methods. Cases of thrombosis and embo- 
lism have also been reported, possibly due to the injection of air into the 
uterine sinuses. The advantages offered by it are that it is not only 
prompt in its action, but also very certain. 

ScheePs method, with its modifications, depends upon the drawing off 
of the amniotic fluid, thus causing a more or less extensive separation 
of the membranes from the decidua and rendering the ovum a foreign 
body, which must naturally excite uterine contractions. The point 
selected for penetration or rupture of the membranes may be at the 
internal os, or higher up, so that a valvular opening is obtained. It is 
advisable to prevent, as far as possible, the entrance of air into the 
cavity of the amnion, since it is impossible to say how long it may take 
before the pains set in and the process terminates. Sometimes labor- 
pains come on in two or three hours, but at other times their appaar- 
ance may be delayed for as many days. In the latter case there is 
danger that septic infection may follow the admission of air. Scheel's 
is probably the most certain of the methods employed for the induction 
of labor, but it possesses several disadvantages, not the least of which is 
that in almost every case its employment is followed by a dry labor, if 
the membranes are punctured at the internal os. The fact that the 
amniotic fluid has escaped, and thus left a solid mass, the foetal body 



INDUCTION OF ABORTION AND OF PREMATURE LABOR. 669 

and membranes, to be expelled by the uterus, renders the dilatation of 
the cervix a slower and more painful process. The contractions of the 
uterus are to a great extent ineffective, the laws of hydrostatics no 
longer applying, since the uterus now contains solid and not fluid con- 
tents. Again, it has been found that not infrequently portions of the 
membranes are left in the uterus. The former of these objections can 
be overcome by adopting the modifications suggested and carried out by 
Hopkins and Meissner. They make the puncture some distance above 
the internal os, so that enough of the amniotic fluid drains away to 
bring on uterine contractions, while sufficient still remains behind to be 
of value in dilating the cervical canal for the after-coming parts of the 
ovum. In advanced pregnancy it is best to allow the water to drain 
off slowly. Various kinds of instruments, from a simple pin or finger- 
nail to a complicated aspirating-needle, may be made use of. 

(6) Dilatation of the Cervical Canal. This may be accomplished 
in many ways. It may be called for as the introductory step in car- 
rying out other methods — e. g., Hamilton's — where it is necessary 
to gain entrance for the finger to the uterine cavity. The cervix may 
be dilated, if it is soft enough, by means of the finger, by Barnes' bag, 
or by metal or hard-rubber dilators. Dilatation by means of the 
Barnes' bag is effective and comparatively safe and speedy. It is more 
applicable to the induction of premature labor than of abortion. Dig- 
ital dilatation is in early cases a difficult procedure. Moderate dilata- 
tion with easily sterilized metal or hard-rubber dilators is generally to 
be preferred. (Fig. 392.) Though not always effective, it succeeds in 

Fig. 392. 




Hegar's dilator. 

the majority of cases, and has the advantage of being one of the safest 
methods known. 

When the patient presents herself in the first two or three months, 
and the necessity for putting a stop to the pregnancy is absolute, the 
swiftest and surest method in the hands of a skilled operator is by 
means of dilating and curetting. The procedure resembles somewhat 
that pursued in gynecological cases. The cervix is dilated with a steel 
branched dilator to a half or a full inch. The ovum is then separated, 
if possible, with a dull curette, and the whole is withdrawn with uterine 
dressing-forceps. The cavity is then gone over carefully with a sharp 
curette. Frequently the ovum has to be brought away piecemeal. The 
whole operation can be done in from ten to twenty minutes. It is 
absolutely sure, and with proper precautions should never be dangerous. 



670 OBSTETRIC SURGERY. 



Methods of Inducing Premature Labor. 

For this purpose it is possible to use any of the methods which have 
been spoken of in dealing with the induction of abortion. But, as has 
already been said, in this connection, a new factor is encountered, namely, 
the possibility of obtaining a viable child, while at the same time the 
mother is relieved of a dangerous encumbrance. Whereas in the former 
case the foetus may be regarded as a foreign body, to be gotten rid of 
by the means most conducive to the welfare of the mother, it now pre- 
sents itself as a living being, whose life may be put nearly on a par 
with her own. In choosing methods, then, we are restricted to those 
which will give the infant the best chance of life consistent with the 
safety of the mother. For this reason methods such as that of Scheel,. 
which depend upon the withdrawal of the liquor amnii, are not advis- 
able. Since their use entails a " dry labor," they increase to some 
extent the risks to the child. It will perhaps be more convenient to- 
state, first, the procedure at present adopted by most of the prominent 
obstetricians in this country, and then to speak briefly of the advant- 
ages and disadvantages of the other methods. 

Operation. The cervix is dilated gradually to one inch with a steel 
branched dilator. The membranes are then peeled up from the lower 
uterine segment with a uterine sound or with the finger. This step ha& 
been recommended by Jewett, and in the hands of a skilful operator 
it would seem to facilitate matters a good deal. One or two bougies 
(English Xo. 10 or 12) are then passed between the uterus and the 
membranes. The proximal end of the bougie having been cut off and 
a stylet introduced, the bougie is passed up as far as it will go, the 
lower end, if any remains outside, being seized with a Keith's forceps 
and carried into the uterus bit by bit. The cervix is then packed with 
gauze. Instead of the bougies and gauze, one of the bags recommended 
respectively by Champetier de Ribes, McLean, and Barnes, may be 
used. Labor is usually completed in from twenty-four to thirty- 
six hours. In urgent cases the dilatation may be completed with the 
hands, or, after the os internum is obliterated, by means of w T ater-bags. 
In extreme emergencies Duhrssen's incisions may be employed after the 
os internum is effaced. But, contrary to the practice of this author, the 
incisions should be sutured immediately after labor. 

With respect to the other methods, it may be said that the use of 
drugs is most emphatically to be condemned. Scanzoni's method is- 
uncertain and painful, and possesses only historical interest. Tampon- 
ade of the vagina is a fairly reliable and a safe method. In placenta 
previa the colpeurynter is to be preferred. Both these and Kiwisch's 
method are slow in their action, but they offer the advantage of pre- 
serving the membranes unruptured. Krause's method is one of the 
best which we possess, more especially if care be taken not to puncture 
the membranes. Hamilton's method and Tarnier's method are reliable, 
and are comparatively easy to carry out. Cohen's method is equally 
certain, but it is not so simple a procedure, and is objectionable on 
account of the danger of the injection of air into the uterine sinuses. 
ScheePs method and its modifications have the disadvantages attaching 
to a dry labor, but when the fcetus is dead and the case is not urgent it 



INDUCTION OF ABORTION AND OF PREMATURE LABOR. 671 

is one of the best at our disposal. " It is often slow in its provocation 
of uterine contractions, but when these have been once established 
delivery as a rule is speedy. Although many living and viable children 
have been born in cases in which it has been employed, when the 
chances for the child's life are weighed the method must be considered 
inferior to those in which the amniotic membranes are left intact. The 
employment of tents, apparently even under the most aseptic precau- 
tions, for dilatation of the cervical canal has often been followed by 
infection. Tarnier's procedure is better, and is not difficult to carry 
out. Digital dilatation is comparatively simple, and, although some- 
times slow, has been effected in an hour or two by many operators. In 
general, therefore, it may be said that in urgent cases — e. g., in eclamp- 
sia — where it is necessary to empty the uterus as quickly as possible, 
the method first described, or some modification of Tarnier's procedure, 
is to be preferred. In cases of placenta prsevia with severe hemorrhage 
the colpeurynter is highly efficacious. When the case is less pressing 
it is always advisable to be content with gradual dilatation, and to 
leave the bag of waters unruptured till later. All other things being 
equal, the method • should be chosen in which the individual operator 
has the most experience. The procedure of Krause and Tarnier and 
the employment of the colpeurynter are all applicable. 

After the expulsion of the ovum in abortion or premature labor the 
membranes and placenta should be minutely examined, and we should 
make sure that the uterus has been completely emptied. If this has 
been done, and if all the necessary manipulations have been carried out 
with strict aseptic precautions, a normal puerperium may be expected. 
The management of such cases is similar to that after spontaneous 
labor. 



Retained and Adherent Placenta. 

It occasionally happens that the birth of the foetus is followed almost 
immediately by the delivery of the placenta. But, as a rule, from ten 
to thirty minutes may be devoted to the necessary care of the mother 
and child, while the expulsion of the placenta is awaited. During this 
time the uterus should carefully be watched, the hand of the nurse or 
doctor being kept on the abdomen to control the fundus. 

Retained Placenta. Not infrequently the uterine contractions, to- 
gether with the pressure exerted by the abdominal muscles, fail to 
cause the delivery of the placenta, which in such cases is usually found 
resting in the uterus. To such a condition the term retained placenta 
is applied. 

Adherent Placenta. More rarely the placenta is not only retained in 
uter o, but it remains fastened to the uterine wall. To this condition the 
term adherent placenta is applied. Of necessity, an adherent placenta 
must also be a retained placenta, but since the converse is by no means 
true, for the sake of simplicity, in describing the methods of dealing with 
such cases, it is more convenient to keep the two conditions distinct. 

Mechanism of Placental Separation. To obtain a clear idea of the 
subject it is necessary to understand the mechanism which brings 
about the natural detachment of the placenta from the uterine walls. 



672 OBSTETRIC SURGERY. 

The chief factor is the expulsive force of the uterine contractions. As 
the uterus becomes smaller the area of the placental site is lessening, 
tending to separate the placenta from its attachment. The expulsion 
of the placenta may take place in either of two ways. The first few 
contractions of the uterus after the completion of the second stage may 
be sufficient to loosen the placenta entirely, and to expel it folded length- 
wise of the uterus in a more or less fusiform shape. They may not, 
however, detach the whole placenta, but only its central portion. The 
marginal attachment may still remain, blood collecting in the cavity 
formed between the central portion of the placenta and the uterine wall. 
The blood-accumulation, together with further contractions of the uterus, 
then forces the placenta down through the opening in the membranes, 
so that it emerges by its amniotic surface from the outlet, dragging the 
membranes after it. In either case, normally all the placenta, together 
with the membranes and the superficial layer of the decidua, should be 
expelled. 

Causes of Retention of the Placenta. The placenta may be retained in 
the uterus by reason of feeble contractions, or, in other words, from 
inertia uteri. A full bladder, a rectum packed with faeces, or a pelvic 
tumor may act reflexly to prevent the efficient action of the expulsive 
forces. Sometimes, though wholly expelled from the uterine cavity, it 
may still be retained in the roomy vaginal vault. 

Causes of Adherent Placenta. One of the most frequent factors lead- 
ing to adhesion of the placenta to the uterine wall is syphilis. A non- 
specific placentitis is a very rare condition, and when present it may lead 
to adherent placenta. A chronic endometritis is sometimes responsible 
for this complication. 

Treatment of the Retained Placenta. It is a cardinal rule, as a pre- 
caution against infection, to allow nothing, whether finger or instrument, 
to enter the uterus or vagina after labor, if possible to avoid it. The 
risk to the patient, even in these days of asepsis, is greatly increased by 
manipulations Avithin the passages at this period. Should the expulsion 
of the placenta be delayed beyond half an hour, it is well to try, first, 
the effect of emptying the bladder. It not infrequently happens that, 
although it may have been carefully emptied before, the bladder becomes 
distended during the progress of the second stage of labor, and its evac- 
uation may succeed in evoking vigorous uterine contractions and the 
prompt expulsion of the placenta. 

If it be quite certain that the bladder and rectum are empty, Credo's 
method of expulsion should be tried. Traction upon the cord is not 
permissible. When the placenta is not yet detached from the uterus, 
pulling upon the cord may cause a partial separation, with alarming 
hemorrhage. Bough traction may even result in complete inversion 
of the uterus. If the use of Crede's method does not prove successful 
at the first attempt, it may be employed repeatedly and patiently at 
intervals, but no violence should be used. Well-directed manipulation 
according to Crede's method rarely fails if the fundus is carried well 
backward to bring the uterus nearly in line with the vaginal axis, and 
the woman is requested to " bear down " forcibly during the manipula- 
tion. As the placenta is being delivered, the membranes should be 
twisted gently into a cord and the whole slowly withdrawn. This pro- 



PLATE XXXVI, 




Manual Extraction of Placenta. 



INDUCTION OF ABORTION AND OF PREMATURE LABOR. 673 



oedure facilitates their removal and tends to prevent leaving behind 
fragments that may favor hemorrhage or infection. If expulsion be not 
effected by expression after a thorough trial, it will be necessary to 
institute a careful examination, in order that the cause of the retention 
may be determined. Should the placenta be found lying in the upper 
part of the vagina, it can be withdrawn gently by means of one or two 
fingers pushed up past it and then hooked over its upper margin. The 
extraction may be assisted by pressure from above through the abdominal 
wall. 

Fig. 393. 




Manual extraction of placenta from lower uterine segment. (After Ribement Dessaignes 

and Lepage.) 



Treatment of Adherent Placenta. When an examination shows that 
the placenta still remains in the uterine cavity notwithstanding the manip- 
ulations that have been described, we may reasonably suspect adherent 
placenta, and should take steps at once for bringing it away. In pre- 
antiseptic days the expectant treatment may have been allowable in 
view of the fact that the removal of the adherent placenta was considered, 
and justly so, a dangerous operation, the mortality being from 7 to 9 
per cent, of cases so treated. The patient and persistent use of Credo's 
method may bring about the separation and expulsion of a moderately 

43 



674 OBSTETRIC SURGERY. 

adherent placenta. "Where this has not succeeded after one or two hours, 
or earlier if hemorrhage is occurring, we must proceed to extraction. 
Chloroform or ether "should be administered to light secondary an- 
aesthesia, and the outer genitals of the woman and the hands and arms 
of the surgeon should be rendered as nearly as possible sterile. The 
cord is taken in the left hand and gentle traction is made till the slack 
is taken in ; the right hand and forearm are inserted into the vagina, 
the fingers following up the umbilical cord as a guide to its insertion. 
The so-called hourglass contraction, formerly so much spoken of as inter- 
fering with the manual extraction of the placenta, is caused by the 
meeting of the dilated or easily dilatable lower uterine segment with 
the more firmly contracted and less dilatable upper segment at the 
retraction-ring. * Should there be trouble at first in entering the uterus, 
either at the cervix or at the site of the retraction-ring, it can generally 
be overcome by the patient application of gentle pressure. The edge 
of the placenta having been found, the fingers are gradually worked 
under it, and sweeping movements are made until the adhesions are 
broken up. The procedure may sometimes be facilitated by inserting 
two fingers held widely apart between the placental surface and the 
uterine wall, and then bringing them together like the blades of a pair 
of scissors. In the meantime counterpressure should be made through 
the abdominal walls upon the fundus, either with the operator's left 
hand or by an assistant. It must be insisted again that all attempts 
at extraction by pulling on the cord be avoided. After all the adhe- 
sions have been broken up, the margin of the placenta is carefully 
caught by a finger, and the whole mass lying on the palm of the hand 
can be forced out of the uterus. A careful examination of the mem- 
branes and of the placenta should then be made by an assistant, to learn 
if fragments have been left behind. It is better that, before removing 
his hand from the uterus, the operator make sure that the evacuation 
has been complete. Should fragments still remain in the uterus they 
should be at once removed by the hand, which may be supplemented, 
if need be, by the curette. These manipulations should be followed by 
an intra-uterine douche of normal salt solution, care being taken that 
no air is introduced. One or more full doses of ergot are usually 
advisable after the evacuation of the uterus has been completed. 



CHAPTEK XXXI. 

THE FORCEPS. 

The obstetric forceps 1 is essentially a pair of steel hands for grasping 
the foetal head and extracting it from the birth-canal in certain emer- 
gencies in which the natural powers are inadequate. 

The invention is generally credited to Peter Chamberlen, an English 
obstetrician. It was for many years kept secret by the Chamberlen 
family. The instrument of Chamberlen consisted of two arms with the 
blades shaped to fit the foetal head. The arms crossed each other, 
articulating at the point of intersection. 

In 1723 Jean Palfyn, a professor of surgery at Ghent, presented to 
the Academy of Science at Paris an obstetric forceps with parallel arms 
articulating at the lower ends. In both the Chamberlen and Palfyn 
instruments the cephalic ends were provided with a single curve only, 
and that on the flat, in conformity with the shape of the head. Levret, 
in France, and Smellie, in England, at about the same time (1747 to 
1751) introduced important improvements in the forceps, chief of 
which was a second curve, adapting it to the curvature of the pelvic 
axis. On their patterns are based the various models in use at the 
present day. 

The obstetric forceps, however, is an invention of much greater 
antiquity than is generally supposed. Crude patterns of forceps are 
known to have been in use several centuries before the Christian era. 

Description. The modern obstetric forceps consists of two interlocking 
crossed arms or branches. The arms are distinguished as left and right, 
the one passed on the left side of the pelvis being the left arm, and con- 
versely. Each has four parts — handle, lock, shank, and blade. 

The handles when the arms are locked fall together so as to be both 
conveniently grasped by one hand of the operator. They are sometimes 
made smooth, but for a more secure hold are generally roughened or 
corrugated on their outer margins. A knob at the lower end adds to the 
security of the grasp. There is usually a transverse projection at the 
upper end of each handle over which a finger may be hooked when mak- 
ing traction. An adjustable screw or other device between the handles, 
to limit the compressed action of the blades, as provided in some forceps, 
is of doubtful utility. The regulation of the pressure upon the head during 
traction is a matter which is better left to the judgment of the operator. 
The handles are best made of metal, or other material which will admit 
of sterilizing by heat. 

The blades in the prevailing patterns of forceps have a double curve 
— a cephalic and a pelvic. The former adapts them to the shape of the 
foetal head, the latter to that of the birth-canal. 

1 The word " forceps " is a singular noun ; the use of the term as plural is a common error, and 
it is equally erroneous to speak of a pair of forceps when only one instrument is meant. 

( 675 ) 



676 OBSTETRIC SURGERY. 

The cephalic curve is essential to all midwifery forceps. It is some- 
what elliptical rather than circular, since the former better accommodates 
itself to heads of different sizes. The head curve in best models is from 
15 to 18 cm., 6 to 7 inches, in length. This gives room for the largest 
possible cephalic seizure. When the instrument is locked the greatest 
distance between the blades should be about 7.5 cm., 3 inches. With 
a smaller interval blades of proper length would be too nearly straight, 
and their hold upon the head insecure ; with a greater width the maternal 
soft parts w T ould be needlessly exposed to injury. 

The interval between the tips when the instrument is closed should 
not be less than 25 mm., 1 inch, otherwise the child's head may be 
injured. 

It is desirable that the point of greatest divergence between the blades 
be not more than 7.5 cm., about 3 inches, from the tips, since the head 
is pressed toward the tips during traction and would be exposed to injury 
if the interspace at the upper part of the blades were too narrow ; more- 
over, rotation would be hindered. 

The pelvic curve of the blades should be such that when the closed 
instrument lies on its back, on a plane surface, the centre of the tips 
shall be about 8.8 cm., about 3 J inches, above the plane. A greater 
curvature is better suited to high and a lesser one answers for low opera- 
tions. But for general use an average pelvic sweep is required. In the 
usual pattern the cephalic and the pelvic curves are nearly equal. A third 
or perineal curve, to be found in some obsolete patterns, is cumbrous and 
useless. 

The shanks connect the handles and blades and are necessary to give 
the length required for high operations. 

The loch in all models of forceps is based either on the Smellie or the 
Levret model. The former is constructed on the principle of a mortise 
and tenon ; in the latter there is on the left or lower half a thumb-screw, 
or a pin surmounted by a button, and in the edge of the other half a 
notch into which the pin or screw fits. It is essential that the articula- 
tion be loose enough to permit locking easily, yet at the same time it 
should hold the arms securely in proper relation with each other. Obvi- 
ously the farther the lock from the handle, the greater will be the lever- 
like action of the forceps in compressing the head. It should be so 
located as to permit a sufficiently firm grasp of the head without undue 
pressure upon it. To this end it is usually placed about one-third way 
from the proximal to the distal extremity of the instrument. 

In the prevailing models of forceps the blades are fenestrated. This 
not only conduces to lightness, but more evenly distributes the pressure. 
The open blades, too, take up less room than the solid. The fenestra is 
usually from 8 to 13 cm., 3J to 5 inches, in length, and is wide enough 
to leave a rim of 1 cm., f inch, in width. By some authorities solid 
blades are preferred. 

Short, straight forceps, so called, about two-thirds the full length, and 
having no pelvic curve, is popular with some obstetricians for very low 
operations. A single long double-curved forceps, however, usually 
serves well all purposes for the general practitioner. 

The instrument should be made of the best tempered steel. Some 
degree of elasticity is desirable, yet there must be rigidity enough to 



THE FORCEPS. 677 

hold the head securely. In order to do this the weight should be so 
distributed that the shanks are strong and nearly unyielding, and the 
blades light, especially toward the tips. Yet it is essential that the 
blades have sufficient thickness to permit rounding off their edges. This 
is particularly important at the tips and at the margins of the fenestra?. 
A common fault with forceps is too great sharpness of the edges of the 
blades, and injuries of: the scalp are of frequent occurrence in consequence 
of this defect. 

The instrument should be kept well polished to facilitate its applica- 
tion. Smoothness of surface and freedom from cracks and crevices 
are conducive to cleanliness, but are not essential to asepsis if heat is 
employed for sterlizing. 

Of the numerous models of forceps, those most used in this country 
are the Simpson, the Wallace, the Hodge patterns, and the Elliott, a 
modification of the Edinburgh instrument. In England the forceps 
of Simpson and of Barnes, in France that of Pajot and of Dubois, 
and in Germany the Naegele and the Braun forceps are commonly em 
ployed. 

Function of the Forceps. The essential function of the forceps is trac- 
tion. It is intended to replace or to supplement the natural expulsive 
forces. 

Fig. 394. 




The author's forceps. 

Its use as a compressor, a lever, or a rotator is only exceptionally 
justified. 

Much compression of the head by forceps is dangerous to the child. 
This is especially true when the head is seized in an oblique diameter, 
which is frequently the case as the instrument is usually applied. 

Brain injuries, sometimes serious enough to cause the death of the 
foetus, are not infrequent results of instrumental delivery. Again, com- 
pression by forceps affords little or no mechanical advantage for extrac- 
tion, since in most seizures the reduction of one elongates the opposite 
transverse diameter. Moreover, when the forceps is applied in relation 
with the lateral walls of the pelvis the compression obtains in the direction 
in which there is usually most pelvic space and in which the reduction is 
least needed. 

It must be remembered, too, that the more rigid the grasp of the head 
the more the natural mechanism is interfered with. 

Moulding of the head is better trusted to the pressure of the pelvic 
walls, which applies compression only where it is needed, lengthens the 
head diameters only in the direction of the birth-canal, and inflicts a 
minimum of injury. The intentional use of the forceps as a compressor 
must be condemned. The aim should be rather to make the pressure of 
the blades light enough, if possible, to leave no marks upon the child. 



678 OBSTETRIC SURGERY. 

A certain amount of compressive action, however, while undesirable, 
is unavoidable. It results necessarily from the grasp required to hold 
the handles, and it increases with the strength of the tractile force. It 
is evident that the risk of foetal injury from pressure is diminished by 
a slow and gradual delivery with the least possible expenditure of force. 
The compression should not only be gentle, but also be intermitted, as a 
rule, at frequent intervals. A forceps with short handles, having little 
compressive power, lessens the danger to the foetal head. 

The lever action of forceps is developed by pendulum movements of 
the handles during traction. This is to some extent a mechanical gain, 
the resistance being overcome in detail. Less force is required to move 
down first one side of the head, then the other, than to move both 
together. This practice, however, is not free from danger to the mater- 
nal soft parts, and is seldom to be recommended. That part of the wall 
of the passages about which as a fulcrum the lever acts is bruised under 
the pressure of the blade. These remarks refer especially to the lateral 
movements of the forceps practised by some operators. Swaying the 
handle- in a sagittal direction is even more objectionable, since the pas- 
sages are more likely to be injured by the edges of the blades than by 
their broad flat surfaces. Generally a steady pull is best. Direct trac- 
tion not only imitates the action of the natural powers, but it inflicts the 
least traumatism, and is all-sufficient for the purpose. 

As a rotator the forceps, except in trained hands, is a dangerous instru- 
ment. Attempts at correcting malpositions with forceps may result in 
laceration of the passages. This is true even of the straight forceps, 
and especially so of instruments with the usual pelvic curve. 

Faulty positions should, if possible, be reduced by manual interfer- 
ence before the forceps is applied. In delayed rotation it is sometime- 
permissible to draw the leading pole forward with the fingers. Rarely 
rotation maybe assisted with the forceps. When the head has not been 
seized primarily in the biparietal diameter, the blades should occasionally 
be readjusted as the head descends, and care must constantly be taken that 
the influence of the natural agencies for producing rotation is not resisted. 
Most essential is a light grasp of the forceps, with the hands near the 
lock, permitting the greatest possible freedom of head movements. 
Rightly applied the blades will usually be kept in position by the press- 
ure of the pelvic walls, and a strong hold upon the handles is not re- 
quired to prevent slipping. 

Prerequisites and Contraindications to the Use of Forceps. Before resort- 
ing to forceps the obstetrician must satisfy himself that the following 
conditions are present : 

1. The relative size of the head and pelvis must be such as to make 
the extraction safely possible for mother and child. The election of 
forceps is not to be based on the pelvic measurements alone. The size 
and plasticity of the foetal head must be estimated. Approximate meas- 
urements of the head may be made with calipers through the abdominal 
wall. The presence or absence of disproportion may be determined, 
too, by noting whether the head has sunk into the excavation or can be 
made to do so with suprapubic pressure, and, if necessary, by exploration 
with the hand in the uterus. AVell-defined osseous obstruction or much 
narrowing of the canal from other causes should, as such, preclude the 



THE FORCEPS. 679 

use of forceps. Its alternatives must be considered when the resistance 
is too great to be overcome with violent traction. 

2. The head must be of nearly normal size and consistence if it is to 
be securely grasped by the blades. The cephalic curve of the forceps is 
best adapted to heads of average size. An easily compressible head is 
equivalent to a small head. An undeveloped, a highly macerated, or a 
perforated head is not suited to forceps, a firm hold being impossible. 
In marked hydrocephalus and in excessive development from whatever 
cause, not only is the resistance too great, but the divergence of the 
blades is excessive and their grasp insecure. 

3. The child must be living and viable, except the extraction is to 
be an easy one. When the delivery of a .dead child by forceps would 
be at all difficult, perforation should be substituted. 

4. The position of the head must be favorable. When possible, mal- 
positions are to be corrected by manual interference. This is not always 
practicable after the head has sunk deeply into the pelvis. One of the 
refinements of modern forceps operations is the correction of certain 
malpositions with that instrument. 

5. It is desirable that the head shall have engaged in the brim; in 
other words, shall have descended far enough to bring the biparietal 
diameter to the level of the inlet, or that it can be crowded down to that 
extent by suprapubic pressure. By many authorities forceps is rejected in 
favor of version before engagement. When the head is free above the 
brim the proper application of the blades is difficult or impossible. At 
best the cephalic mass will be caught obliquely by one side of the occiput 
and the opposite side of the sinciput. In this seizure not only is the 
pressure of the blades dangerous to the child, but it tends to bring about 
premature flexion and rotation, and thus to increase the resistance. Yet 
the widely accepted rule, version before and forceps after engagement, is 
subject to exceptions. This is especially true since the introduction of 
the axis-traction instrument. When the waters have drained away and 
the foetus is firmly invested by the uterus, version is a difficult and 
dangerous operation. Forceps in such conditions often serves better the 
interest of both patients. In general, when the conditions are favorable 
for an easy forceps extraction, the latter is preferable to a difficult 
version. No attempt to apply the blades, however, must be made till 
the head has been pressed down as deeply as possible and so held by an 
assistant. 

6. The cervix must be fully dilated or easily dilatable, otherwise dan- 
gerous laceration of the lower uterine segment may result. In emer- 
gencies, recourse may be had, if necessary, to manual dilatation, and 
sometimes multiple shallow incisions of the lower border of the cervix. 

7. The membranes must be ruptured and retracted above the head. 
Should the membranes be caught in the grasp of the blades, the placenta 
may prematurely be torn partially or wholly from its attachment. 

Indications for Forceps. The necessity for forceps delivery may arise 
from anomalies (1) of the expellent forces, (2) of the passages, (3) of the 
passenger, or (4) in consequence of some complication of labor independ- 
ent of the mechanism. 1 

1 The indications for forceps will be found more fully treated under Anomalies of the Mechanism 
of Labor. 



680 OBSTETRIC SURGERY. 

1 . Forces at Fault. Failure of the pains is not of itself alone an indication 
for forceps. The physician cannot justify himself in applying forceps to 
save his own time. Inertia uteri in the presence of conditions likely to 
jeopardize the interests of mother or child may call for instrumental de- 
livery when simpler measures have failed. Here, as elsewhere, forceps is in- 
dicated when its dangers are less than those of delay. Important elements 
in the question are the strength and endurance of the mother as indicated 
by the force and frequency of the pulse, the presence or absence of 
exhausting pain, the quality and strength of the foetal heart tones, and 
the probable difficulties of the operation. Impending exhaustion on the 
part of the mother is a frequent occasion for instrumental delivery. Just 
when forceps is permissible under this indication is often a delicate 
question requiring the exercise of critical judgment. As a rule, wdien 
the head is low down in the passages and has been arrested for a 
half-hour because of feeble pains, the labor should be terminated with 
forceps. 

2. Passages at Fault. Marked osseous obstruction, as already observed, 
forbids the use of forceps. Yet moderate narrowing does not necessarily 
debar. The limit of contraction for forceps is variously stated by differ- 
ent authorities as from 8 to 9.5 cm., 3 \ to 3f inches. But methods of 
treatment in deformed pelves cannot be formulated on pelvic measure- 
ments alone. The choice of procedure must rest on the relative size of 
head aud pelvis. Pelvic contraction is an indication for forceps only 
when the plasticity and size of the head permit. The field of forceps 
is somewhat extended by axis traction and by the Walcher posture. Yet 
if the child is living and viable, symphyseotomy or Cesarean section is 
generally better, in the interests of both patients, than a very difficult 
forceps delivery. 

As against version, in slight contraction, forceps has the advantage 
that under modern methods the pull is in the pelvic axis, more time 
is permitted for delivery, and the uterus is less exposed to both 
septic and mechanical injuries. It is easier to sterilize instruments 
than hands. 

Tentative use of forceps is permissible in moderate obstruction in the 
soft parts. 

3. Passenger at Fault. Forms of foetal dystocia amenable to forceps 
are met with in occipito-posterior positions, in mento-anterior face cases, 
and in pelvic presentation with the breech arrested in the excavation. The 
instrument is superior to other methods in certain difficult extractions of 
the after-coming head. Evidence of foetal exhaustion or asphyxia, pulse 
above 160 or below 100 to the minute, may necessitate immediate instru- 
mental delivery. Forceps is contraindicated in high transverse positions 
of the face, owing mainly to the danger to the child from pressure of the 
blades upon the vessels of the neck. The delivery of a posterior-face 
case is impossible as such, yet attempts at instrumental rotation may 
sometimes be permissible. 

4. Accidental Complications. Complications of labor sometimes de- 
manding forceps are hemorrhage, prolapsus funis, rupture of the uterus, 
eclampsia, and all acute and chronic diseases or other complications of 
labor in which immediate delivery is required in the interest of mother 
or child or both. 



THE FORCEPS. 681 

In general the low operation is frequently justifiable on minor indica- 
tions, the high operation only on major indications. 

Dangers of the Forceps Operation. Accidents to which the mother is 
exposed and which are not always preventable in forceps delivery are 
slight contusions and lacerations of the passages. Injuries to the uterus, 
to the vagina, and especially to the pelvic floor are more frequent than in 
spontaneous labors. Most liable to tear are the cervix and the vaginal 
orifice, since the resistance from the soft parts is usually greatest at these 
points. Serious accidents are, unfortunately, common in careless and vio- 
lent forceps deliveries. A cervical tear may invade the body of the uterus 
and enter the peritoneum. Pelvic floor injuries not infrequently destroy 
the recto-vaginal septum. Owing to faulty application or to unguarded 
traction, the blades may slip from the head either vertically or horizon- 
tally and be dragged abruptly through the passages. Even serious blad- 
der wounds and perforation of the posterior vaginal fornix may occur at 
the hands of the careless or the inexpert. If the handles are carried too 
far forward or backward during traction, the vaginal walls may be cut by 
the tips of the blades. Misdirected traction exposes the maternal soft 
parts to needless injury, and even rupture of the pelvic joints is possible 
in violent instrumental delivery. The difficulty of extraction may be in- 
creased in the unskilful use of forceps by hindering the normal mech- 
anism. 

The danger is obviously greater the higher the head in the pelvis, since 
the control of the instrument is more difficult and injuries to the upper 
portion of the passages more serious.- The head before it has fully 
engaged in the brim is imperfectly moulded, the grasp is bad, the normal 
head movements are impeded, and the difficulty of extraction is increased 
accordingly. 

To the child the risks of forceps delivery are greater than to the 
mother. Intracranial hemorrhage from injuries to the meningeal or 
cerebral vessels is not an infrequent result of compression in difficult, 
and this sometimes occurs in easy, forceps extractions. Injurious press- 
ure may arise from rapidly dragging an unmoulded head through the 
pelvis as well as directly from too forcible grasp of the blades. A con- 
siderable foetal mortality is attributable to these injuries, and permanent 
mental and physical infirmities may result in children who survive them. 
Hemiplegia, idiocy from cerebral atrophy, psychical disorders, and even 
epilepsy in later life are believed to be possible consequences of these 
lesions. The region of the lower anterior angle of the parietal bone is 
the most vulnerable one. 

When the cord is coiled about the child's neck it is exposed to press- 
ure from the tips of the forceps blades and fatal asphyxia may ensue. 
Facial paralysis results most frequently from compression of the facial 
nerve-trunks, but may occur from the pressure of an intracranial blood- 
clot. The former injuries are usually unimportant, the paralysis disap- 
pearing within a few days. Injuries to the brachial plexus have occurred 
in forceps operations, but probably from stretching the nerve-trunks 
rather than from pressure effects. Abrasions, indentations, lacerations, 
and contusions of the scalp, face, and eyeballs are common in instru- 
mental delivery. Yet anything more than slight or transient markings 
must be regarded as a reproach upon the skill of the operator. Deep in- 



682 OBSTETRIC SURGERY. 

dentations of the skull or fracture of the cranial bones can result only 
from culpable ignorance or carelessness. 

Fatal asphyxia is common after births terminated with forceps. This 
may result from premature efforts at respiration provoked by peripheral 
irritation, or from the inhibitory effect of brain compression on the car- 
diac movements through irritation of the vagus. When head and pelvis 
are proportionate the skilful and timely use of forceps should, as a rule, 
diminish rather than increase the foetal mortality. 

Preparation for the Forceps Operation. The bladder and the rectum 
are to be emptied; either of these viscera if distended may suffer serious 
injury from the forceps. The cleanliness of the operation may be pro- 
moted by thoroughly 'washing out the lower bowel as a preliminary 
measure. 

The quality and the frequency of the foetal heart tones should be noted 
and should be listened for at intervals during delivery. Anaesthesia 
to the surgical degree is generally advisable, and for this purpose ether \ as 
a rule, is to be preferred. In low operations mere obstetric anaesthesia often 
suffices, or none at all may be necessary. In all prolonged and difficult ex- 
tractions complete narcosis is required. The administration of the anaes- 
thetic should, if possible, be entrusted only to a skilful medical assistant, 
and should be managed in accordance with the usual rules of surgical 
practice. 

The abdomen, the thighs, and especially the external genitals are 
rendered as nearly aseptic as possible. Particular care is given to 
the cleansing of the vulva and its immediate surroundings. If the 
vagina is healthy and has not been exposed to unclean contact during the 
labor or for some hours before, no internal antisepsis is required. When 
the vagina or cervix is diseased or there is reason to believe they have 
been infected, the passages should be prepared with the same care as are 
the external genitals. They are cleansed with soft soap and hot water, with 
the aid of general friction, for five minutes, care being taken to prevent 
abrasions. The friction is best applied with the fingers or with a soft 
cotton ball held in the grasp of a suitable forceps. A sublimate douche 
1 : 4000, or other equally active antiseptic solution, is then to be employed 
for the same length of time, the friction being continued. The lubrica- 
tion of the parts may, if necessary, be restored by the plentiful use of 
sterilized glycerin or vaseline. In hospitals it is a common antiseptic 
precaution to cover the legs and feet with sterilized leggings or drawers. 
Wrapping them in aseptic sheets suffices, and this method is recom- 
mended in family practice where the leggings are not usually available. 

The operator's hands and forearms are to be prepared as for a major 
surgical operation. A sterilized operating-gown or, in the absence of 
this, an apron or a sheet should protect the physician's clothing against 
contact with his hands. The instrument is best sterilized by boiling. It 
may be wrapped securely in a towel before . sterilizing, and so kept till 
wanted for use. A basin containing a bichloride solution, 1 : 2000, or 
other suitable antiseptic, and one or two squares of cheese-cloth should 
be provided. The antiseptic solution serves for rinsing the hands as 
required and for cleansing the external genitals of the discharges. An 
ounce or two of glycerin or of vaseline which has been sterilized by heat 
may be found useful as a lubricant for hands and instrument. 



THE FORCEPS. 683 

The operation is most conveniently conducted on a firm table which 
lias been properly cleansed, dressed, and covered with a surgically clean 
sheet. When the patient is delivered on the bed, as is usually the cus- 
tom in private practice, the mattress is protected with a rubber sheet. 
The bed-linen and the patient's clothing must be as nearly aseptic as 
possible. A small foot-tub or infant's bath-tub or slop-jar is placed on 
the floor at the edge of the bed to receive the discharges. A rug or a 
table oil-cloth spread under it saves soiling the carpet. 

Indispensable to a successful and safe forceps delivery is an exact knowl- 
edge of the position of the foetal head. In case of the slightest doubt 
or any possibility of error, the diagnosis of position should be confirmed 
by passing the hand, if necessary, into the uterus. Finding an ear may 
suffice for determiniug the foetal position, but, as a rule, the entire head 
should be examined. This examination can best be made after the 
patient has been placed under the anaesthetic. With the aid of anaes- 
thesia and with the hand in the uterus it is possible in every case to know 
with absolute certainty the position of the head. 

The cervix must be fully dilated or so soft and yielding as to permit 
the passage of the head without risk of tearing. Dilatation may be com- 
pleted if necessary with the hand or by means of a w T ater-bag, and even 
multiple incisions to the depth of half an inch are permissible in emer- 
gencies requiring prompt delivery. 

Posture of the Patient. In this country, in France, and in Ger- 
many the position generally preferred for ordinary forceps delivery is the 
partial or complete lithotomy position. The patient is placed on her back 
across the bed with the thighs and the legs flexed, and the knees held 
apart, the hips extending over the edge of the bed, or in a similar posi- 
tion on a firm table. One assistant on each side is usually necessary for 
holding the limbs. In the absence of assistants a Robb or Buckmaster 
leg-holder or Dickinson's sheet-sling may be utilized for the purpose. 

The left lateral position is usually adopted in England for forceps 
delivery, and is known as the English position. 

Watcher's Position. It is well known that the sacrum, especially in 
in the later months of pregnancy, is capable of a slight nutatory motion 
on a transverse axis passing through its second vertebra. Walcher, in 
1889, called attention to the importance of utilizing the mobility of the 
sacro-iliac joints in difficult labor. The sacral promontory lies in a plane 
above the axis of rotation and in front of it. The promontory, there- 
fore, moves forward and backward according to the changing inclination 
of the pelvis in different postures of the body, and the tip of the sacrum, 
of course, moves in reverse direction. When the woman lies in the lith- 
otomy position, the thighs being strongly flexed upon the abdomen, the 
conjugate diameter of the pelvis is shortened; when placed in the dorsal 
position with the hips close to the edge of the table and the lower 
extremities hanging, that diameter is lengthened. The latter posture is 
known as Walcher' s position. (See Plate XL) The gain in the con- 
jugate on changing from the lithotomy to the Walcher position is variously 
estimated at from 5 to 13 mm. In a series of observations made by the 
writer the increment was, in the cadaver of the non-puerperal subject, 3 
mm., and in the living woman within two weeks after labor, from 5 to 7 
mm. The gain, though small, may be utilized to advantage in moderate 



684 



OBSTETRIC S UR GER Y. 



disproportion between head and pelvis. In difficult extractions the 
patient should be placed with the thighs in full extension till the largest 
circumference of the head has passed the brim. On the other hand, the 
dorsal recumbent posture, thighs moderately flexed and knees held apart, 
and especially the extreme lithotomy position is best during the extrac- 
tion of the head through the outlet of the bony pelvis. 

The Operation. The operation is spoken of as high, low, or medium, 
according to the situation of the head in the passages; it is high when 
the head is at the superior strait or barely engaged therein, low when it 
rests on the pelvic floor, and medium in intermediate situations. These 
operations differ in the extent and character of the manipulations 
involved, not only by reason of the changing direction of the birth- 
canal, but also because of the varying positions of the foetal head at 
different stages of descent. Low forceps delivery is a comparatively 
simple undertaking; the high operation is one demanding the utmost 
skill and tact. 

Fig. 395. 




Cephalic application of forceps over the parietal eminences. (Farabeuf and Varnier.) 



The Application of the forceps may be cephalic or pelvic. In the 
former the head is seized transversely, the blades resting over the pari- 
etal eminences (Fig. 395); in the latter the blades are applied in rela- 
tion with the sides of the pelvis without reference to the head. 

Application to the sides of the head has the following advantages : 
The grasp is symmetrical, the blades fit better, they do less injury to the 
head, the normal mechanism is less disturbed. 

When the blades are applied to the sides of the pelvis the head is 
usually caught obliquely; in high applications the grasp falls over one 



THE FORCEPS. 685 

frontal bone and the opposite side of the occipital — a direction in which 
compression is especially harmful and the grasp likely to be insecure. 

On the other hand, the pelvic application of forceps is simpler and 
easier than the cephalic, and in inexperienced hands less endangers the 
soft parts of the mother; if the handles are held lightly and the traction 
is intermittent, the pressure on the head is usually well borne. 

In low operations, rotation being complete or nearly so, application to 
the sides of the pelvis brings the blades at the same time in relation with 
the sides of the head. It is only in high or medium cases that the choice 
of methods must be considered. In high operations the difficulty and 
danger of the cephalic application are, as a rule, too great to justify the 
inexperienced operator in attempting it. On the whole, the beginner will 
do well to content himself, as the vast majority of physicians in general 
practice do, with the pelvic application of forceps. The expert will 
best serve the interests of both patients by electing the cephalic. When, 
however, it becomes necessary to bring the head down through the 
brim, the blades are to be adjusted first in a transverse diameter of the 
pelvis; after the head has entered the excavation the instrument may be 
readjusted or removed and reapplied over the parietal bones. 

Steps of the Operation. The operation comprises four steps : The 
introduction of the first blade; the introduction of the second blade; lock- 
ing the forceps; the extraction of the foetus. 

Application with reference to the pelvis, the method most commonly 
pursued, will first be considered. It will be assumed that the head is in 
an anterior position. 

1. Pelvic Application, (a) Introduction of the First Blade. If 
hands and instrument are wet with the antiseptic solution no other 
lubricant, as a rule, is required; should any be needed vaseline or glycerin 
previously sterilized by heat may be used. The latter is the more cleanly. 

For convenience in locking, the left, since it is the lower arm of the 
forceps, is usually passed first. The operator sits or stands as may be 
most convenient. The patient in position and all preparations complete, 
he introduces two or more fingers of the right hand into the vagina with 
their volar surfaces facing his left. They are pushed upward and back- 
ward between the head and the left wall of the passages. If the head 
is still in the uterus care will be required to make sure that the fingers 
are passed within the cervix. The finger tips are carried as far as they 
will go readily, and the cervix is held well outward away from the head. 
The nearer the head to the vulvar orifice the greater the difficulty and 
the less the need of pushing the guiding fingers deeply in the pelvis. 
The left branch of the forceps is now taken in the left hand and the 
blade is introduced, the palmar surface of the hand in the passages serv- 
ing as a guide. The arm of the forceps is at first grasped near the lock 
and is held lightly between the thumb and finger and in a nearly vertical 
direction (Fig. 396). If a firmer grasp is required as the blade passes 
alongside the head the handle may be held in the full hand. The instru- 
ment is pushed gently on in the direction of the passage till it reaches the 
head. From this point the course of the blade is that of a spiral ; it must 
follow both the pelvic and the cranial curves. After it has passed beyond 
the reach of the fingers it is guided by hugging the head with the tip. 
Urged cautiously along, it finds its own way, moving in the direction of least 



686 



OBSTETRIC S UR GER Y. 



resistance. No force is necessary or permissible. Should any obstacle 
be met it must not be overcome by increasing the pressure; the blade 
should be partially withdrawn and its direction slightly altered till it 
slips easily into place. It is carried well up till the tip barely over- 
reaches the head. Should a uterine contraction occur, the manipulations 
should be suspended till it ceases. Usually under anaesthesia the pains 
are in abeyance. 

Fig. 396. 




Application of first blade of forceps. (Zweifel.) 



(b) Introduction of the Second Blade. The right half of the forceps 
is held in the right hand and the blade passed on the left hand as a 
guide, in a manner entirely similar to that already described for the first 
blade. The handle of the first arm may, meantime, be held by an assist- 
ant, or be left to itself (Fig. 397). The application of the second blade, 
while not so easy as the first, is not, as a rule, difficult. 

(c) Adjustment and Locking. The operator now seizes one handle in 
each hand, the thumbs being extended along the upper surface. If the 
blades are properly applied the two halves of the instrument will fall 
into symmetrical positions and will lock easily. If the handles do not 
face each other, push them well back against the perineum; should one be 
higher in the pelvis than the other, push the lower one gently up. In 
high operations it will always be necessary to press the handles as far 
back as the perineum will permit. The locking must never be forced. 
If difficulty is still encountered, the blades should be removed or par- 
tially withdrawn and repassed. With a good seizure, the head being of 
normal size, the handles, while they are not in contact, will not be far 
apart. A common mistake in the application of forceps consists in 
failing to pass the blades far enough. The aim should be to bring the 
head well within the cranial curvature of the instrument. Care must 
be taken that the grasp is not too far forward or backward with relation 



THE FORCEPS. 



687 



to the pelvic axis, and that it does not include a loop of the cord. As 
the arms are locked a finger is swept around the shanks to prevent catch- 
ing the labia or valvar hairs between them. 

2. Cephalic Application. It is assumed that the head has passed 
the brim or is in the excavation. The left blade usually is passed first. 
The guiding fingers are carried up along the side of the head as far as 
they can reach, finding the place where there is most room. The blade 
is then introduced, and, with the aid of one finger hooked under the 
front or the back rim of the fenestra, it is then urged gently sidewise 
into position over the parietal eminence. With changed hands the 
remaining blade is applied in like manner over the opposite parietal 
bone. The internal fingers, pushed up as far as possible between the 
side of the head and the sacro-iliac ligament, guide the blade to its des- 
tination. Should it have been necessary to pass the right blade first, the 
handles must be readjusted for locking. 



Fig. 397. 




Application of second blade. (Zweifek) 



If the forceps is in proper relation to the head it will lock readily. 
It will now be seen that the handles do not lie in the median plane, as 
they do when applied in relation with the sides of the pelvis. In high 
applications they will be found nearly or quite in line with the oblique 
diameter of the pelvic brim, facing strongly to one side. When the 
head is deeper in the pelvis they look more nearly forward. 

(d) Extraction. The forceps being locked, the operator examines to 
assure himself finally that the blades are in proper relation with the 
head. The force and frequency of the foetal heart are noted and are 
listened for at intervals during delivery. 

In easy extractions the pull is applied with one hand while a finger of 
the other is held against the head to give warning should the instrument 



688 OBSTETRIC SURGERY. 

slip. When more force is required both hands are used for traction, and 
examinations are made in the iutervals. 

(a) In Low Operations. In low operations the delivery is effected for 
the most part or wholly under ocular inspection. With the head well 
down on the pelvic floor and in anterior position but little tractile force 
is needed, and the risks of either foetal or maternal injuries are insignifi- 
cant. The forceps is grasped with one hand near the lock, the first and 
second fingers hooking over the projecting shoulders at the upper ends of 
the handles. The least possible compression is thus exerted upon the 
head. In many cases none is required to maintain the grasp. The walls 
of the birth-canal, as a rule, make sufficient pressure to keep the blades 
in place when the seizure is good and little tractile force is employed. 
The palm of the hand may be turned up or down. 

The tractions, like the natural pains, should be intermittent. They 
should continue for about one miuute, and the intervals may be one or 
two minutes. During the intervals the forceps is unlocked to relieve the 
head from pressure. The line of traction must be such that the blades 
are kept constantly in the axis of the birth-canal. 

The extraction of the head may or may not be completed wdth the 
forceps. The thickness of the blades is too small to make any appre- 
ciable difference in the distention of the pelvic floor, yet too great strain 
may be brought upon the resisting soft parts by misdirection of the trac- 
tile force or by disturbance of the normal mechanism of expulsion even 
at the hands of an expert. Injury may inadvertently be done by drag- 
ging the head too heavily against the pelvic floor or by too rapid exten- 
sion. The writer prefers, therefore, to remove the forceps, as a rule, 
when the head has descended so far that it no longer recedes in the inter- 
vals between tractions. The head is then expelled easily by light press- 
ure applied from behind through the perineum. With the fingers of one 
hand upon the occiput and with the other hand laid flat upon the bulging 
surface well back of the posterior vulvar commissure, thumb to one side 
and fingers to the other of the genital fissure, the advance of the head 
is perfectly under control. On no account are the fingers to be intro- 
duced into the rectum for the purpose of shelling out the head. The 
practice is unnecessary and is incompatible with a strict asepsis. 

The forceps blades are removed in the reverse order of their applica- 
tion. Two fingers of one hand are applied over the anterior edge of the 
blade just within the vulva to protect the maternal soft parts. As the 
blade is withdrawn the handle is gradually swept well up over the oppo- 
site groin. Should an obstacle be encountered the blade must not be 
forcibly extracted. If the obstruction cannot be overcome by slightly 
changing the direction of the blade, the latter may be left in place till 
the head is delivered. 

If delivery is completed with forceps the natural mechanism of expul- 
sion must be closely followed. The head is drawn down till the nucha 
is well under the pubic arch. Then by an upward movement of the 
handles the forehead, the face, and the chin are made to sweep in succes- 
sion over the vulvar edge. (Fig. 398.) 

The handles may be held forward during the perineal stage of the 
operation as far as possible without bruising the soft parts between the 



THE FORCEPS. 



689 



anterior edges of the blades and the ischio-pubic rami. This will neces- 
sitate carrying the handles more and more forward and upward as the 
head descends, till at the moment when it escapes they are almost in 
contact with the mother's abdomen. After the pelvic floor begins to 
bulge the instrument is held by the shanks near the lock with the radial 
edge of the hand up. 

Fig. 398. 




Showing the normal course of the head in its descent through the birth-canal. 
(Farabeuf and Varnier.) 



If in doubt as to the extent to which the handles should be swept for- 
ward, let go the handles and observe their position. If the blades are 
in proper relation to the head, the direction which the handles assume 
when left to themselves will be that in which they should be held during 
the next traction. 

During the perineal stage of the operation the head should be pressed 
well up into the pubic arch. The perineum and anal orifice are covered 
with a sterile towel. Over this the hand is held broadly across the 
bulging pelvic floor, the thumb lying along one side and the fingers along 
the other side of the vulva. Firm pressure is made toward the pubic 
arch during traction. This manipulation aids materially in preventing 
pelvic-floor injuries by relieving the fascial structures of the floor of 
excessive strain during extraction of the head. 

In artificial as in spontaneous births time is an important element in 
the prevention of perineal injuries. The extraction must be slow and 
gradual to permit the pelvic floor to stretch. In primiparse, as a rule, 
a half hour will be required for this stage of the delivery, and little less 
in most other cases. 

(b) In High Operations. As a general, if not an invariable, rule, 
axis-traction forceps should be substituted for the classical instrument at 
the superior strait. If the ordinary forceps is used both hands are 
usually required for traction. If a straight pull upon the handles is to 



44 



690 



OBSTETRIC SURGERY. 



be employed they may face each other with the handles flatwise between 
them. The first two fingers of one hand are hooked over the transverse 
projections and upon these fingers rest the corresponding ones of the 
other hand. The remaining fingers of one hand encircle the handles, 
holding them firmly enough only to prevent the blades from slipping. 
When the instrument is rightly applied little or no compression is 
necessary. 

But to act to the best advantage the tractile force must be applied as 
nearly as possible in the axis of the birth-canal. A straight pull on 
the handles wastes a part of the force by dragging the head against the 

Fig. 399. 




Head at superior strait ; right and wrong traction. (Farabeuf.) 

anterior pelvic wall (Fig. 399), and the misdirected force is not only lost, 
but is mischievous. It increases the resistance and adds to the risk of 
both maternal and foetal injuries. Yet with an instrument of mode- 
rate pelvic curve the disadvantage of direct traction on the handles is 
insignificant in easy forceps deliveries. 

Axis traction is possible with the common forceps by Pajot's (Gala- 
bin's) manoeuvre, which is executed as follows : The handles are held 
lightly with one hand near the lock, to avoid much compression, and the 
other hand is applied upon the shanks near the vulva. Pressing down- 
ward with the hand on the shanks while the other pulls upward at the 
handles, the two forces may be so balanced that the resultant shall act in 
the line of descent. If the operator stands by the bed or table, the hands 
are applied above the instrument with the palmar surfaces down (Fig. 
400) ; sitting the hands grasp the forceps palms upward (Fig. 401). 
The mechanical principle involved is also set forth in Fig. 402. 

Line of Pull, A straight line passing through the umbilicus and the 
tip of the coccyx is practically the line of pull till the head reaches the 
pelvic floor ; this line is parallel with the posterior surface of the sym- 



THE FORCEPS. 



691 



physis pubis, which may be taken as the guide. For greater accuracy 
the direction may sweep very slightly backward in conformity with the 
curvature of the sacrum. In all high operations, and especially in pelvic 
distortion, where we have no reliable anatomical guides to the axis of the 
bony canal, the axis-traction instrument, which itself points out the way 



Fig. 400. 




Axis traction with plain forceps, operator standing. Pajot's manoeuvre. 
Fig. 401. 




Axis traction with plain forceps, operator sitting. Pajot's manoeuvre. 

and at the same time permits the greatest possible freedom of head move- 
ments, offers an obvious advantage. 

As soon as the pelvic floor begins to bulge under pressure of the 
advancing head the line of direction turns somewhat abruptly forward. 
From this point the technique does not differ from that of the low opera- 
tion already described. 

The amount of tractile force should not exceed eighty pounds; in the 
Pajot method it can scarcely reach that limit at the hands of most oper- 
ators. In the writer's experience the strength of pull as measurered by 
a dynamometer attached to an axis-traction instrument, has not in the 



692 



OBSTETRIC SURGERY. 



most difficult of justifiable forceps deliveries exceeded seventy pounds. 
In a properly conducted forceps operation the force employed will 
seldom be more than twenty-five or thirty pounds, and it will very 
rarely amount to fifty pounds. 

Traction should be made with the arms only. Bracing the feet and 
pulling with the weight of the body is neither necessary nor permissible. 
The beginning traction should be tentative to make sure that the head is 
properly in the grasp of the blades and that no unusual obstacle or diffi- 
culty is present. 

Since the high operation must be conducted under full anaesthesia, no 
aid is to be expected from the natural pains. Well-directed abdominal 

Fig. 402. 




Showing the mechanics of axis traction with plain forceps. (Fakabeuf and Vaenier.) 

pressure, however, at the hands of a skilled assistant is an efficient help. 
This may be continued with advantage till the head is well down on the 
pelvic floor. 

The rule of a pull and a pause, of about one minute each, should be 
observed, and the forceps be unlocked in the intervals between tractions 
to relax the pressure upon the head. 

General Rules. The normal mechanism of labor must be strictly ob- 
served throughout the descent. As soon as the equator of the head has 
passed the brim rotation begins. While the forward movement of the 
occiput must not be forced it may be favored. When the blades have 
been applied in relation with the sides of the pelvis, they must be read- 
justed as the head rotates in course of its descent. 



THE FORCEPS. 693 

While the head is passing the superior strait the possible advantage 
of the Walcher position should be borne in mind. Traction should be 
moderate, permitting time for moulding of the head. As already stated, 
the cervix, as a rule, should be fully dilated, manually if need be, before 
the application of forceps. The tension of the cervical ring must be 
watched during traction, and time must be allowed for it to yield gradu- 
ally should dilatation prove not to have been complete. If the cervix 
is drawn down to the vulva it may be pushed back over the head gently 
with the lingers of one hand, while moderate traction upon the handles 
of the instrument is applied with the other. 

(c) In Medium Operations. The method of procedure in cases inter- 
mediate between the high and the low operation scarcely needs discus- 
sion. It should be remembered that in the typical relation of head to 
pelvis the sagittal suture approximates the antero-posterior diameter of 
the pelvis only when the head has reached the outlet of the soft parts. 
In the latter situation the blades applied with reference to the pelvis fall 
directly over the biparietal diameter. The higher in the pelvis the more 
oblique will be the seizure of the head in the pelvic application of the 
instrument. 

Forceps in Occipito-posterior Positions. In posterior positions of the 
vertex before engagement forceps is inadmissible. It is the writer's 
practice, if the head is movable at the brim or can readily be pushed up, 
to rotate not the head alone but the entire foetus into dorso-anterior posi- 
tion. Before rupture of the membranes this is frequently possible by 
external manipulation. If the waters have escaped one hand is carried 
into the uterus to the posterior shoulder, which is swept outward away 
from the median line, the anterior shoulder at the same time being urged 
inward toward the median line by the external hand over the abdomen. 
This is done with the aid of full anaesthesia. After bringing the occiput 
to the front the head is crowded into the pelvic brim by external press- 
ure, and the forceps then applied, if necessary. 

If the head has engaged too firmly to permit correction of the mal- 
position, forceps should be withheld as long as possible. In general, 
rotation may be awaited safely so long as the pains are good, the pelvic 
floor resilient, and the conditions of both patients such as to justify delay. 
Except in extreme emergencies, simple measures should be exhausted 
before resorting to instrumental delivery. The operation is more diffi- 
cult and is much more dangerous to mother and child than when the 
occiput confronts the anterior half of the pelvis, and must not be lightly 
undertaken. When forceps must be used, application to the sides of 
the head is desirable, yet it is more difficult than in anterior posi- 
tions. The cephalic application, however, is inadvisable before the 
head has descended into the cavity. Generally, it will be found best 
to introduce the anterior blade first, whether that be the left or the 
right one. A moderately firm grasp will be required to prevent slip- 
ping (Fig. 403). 

In occipito-posterior positions the arrest of the head frequently means 
imperfect flexion. To bring down the occiput, when flexion is incom- 
plete, the line of traction should be somewhat in front of the pelvic axis 
till the forehead clears the pubic arch (Fig. 404). The occipital pole 
may then be lifted over the vulvar edge with the foiceps. The writer, 



694 



OBSTETRIC SURGERY. 



however, prefers to remove the forceps when the head has reached the 
vulvar outlet and to complete the delivery by manual measures. In most 
cases it is possible after the head is well in the grasp of the vulvo- 
vaginal ring to rotate the occiput to the front by manual interference. 
Under backward pressure with the fingers of one hand against the ante- 
rior temple, rotation usually takes place with the utmost facility. The 

Fig. 403. 




Relation of forceps to head in oceipito-posterior position, head well flexed. 
(Farabeuf and Varnier.) 

posterior pole of the head may at the same time be drawn forward with 
the other hand, if necessary. Even should the rotation be difficult there 
is little risk of doing harm to either mother or child by properly directed 
manual efforts. It is commonly stated that the foetal head cannot be 




Oceipito-posterior position, flexion incomplete. Forceps applied over mastoid and pulling forward 
to increase flexion. (Farabeuf and Varnier.) 

turned for more than a quarter circle without danger of injury to the 
atlo-axial articulation. But Tarnier has called attention to the fact that 
the torsion is distributed along the entire upper portion of the spinal 
column, and may safely be carried, therefore, beyond a quarter circle. 
Exaggerated rotation, he thinks, is less dangerous than the excessive 
flexion necessary to delivery in the posterior position of the occiput. 

When manual measures fail the cautious use of forceps in skilled 
hands may serve a useful purpose for rotating the head after it has 



THE FORCEPS. 695 

reached the pelvic floor. It is essential in such use of the instrument 
that the long axis of the blades be kept in the axis of the birth-canal. 
To this end, if the forceps has a pelvic curve, the handles must be car- 
ried well over toward that thigh which confronts the concavity of the 
instrument. The rotation is made through not more than ninety de- 
grees at one effort. Time is then allowed for the trunk to rotate with 
the aid needed of external manipulation. Rotation having been effected, 
the forceps is removed and reapplied with the concavity of the blades 
to the front. As a rotator straight forceps is safer than one with the 
usual pelvic curve. 

Should rotation fail, the delivery is completed with forceps, in accord- 
ance with the usual mechanism of persistent occipito-posterior positions. 
The occiput is drawn well forward and lifted over the posterior vulvar 
commissure. The head is then delivered by a movement of extension 
about the nucha as a pivotal point. 

Forceps in Face Presentation. In mento-posterior face cases forceps is 
contraindicated. In an impacted face position symphyseotomy should 
be considered if the child is living and viable, otherwise the head should 
be perforated. 

In low mento-anterior face positions forceps delivery presents no spe- 
cial difficulty. Judicious attempts at manual rotation are often success- 
ful. Cautious rotation with straight forceps may be tried when other 
methods fail. Extension must be maintained and the mechanism of 
natural delivery be carefully followed. The only safe application is to 
the sides of the head, and care is necessary to secure a firm hold, reach- 
ing well back to prevent slipping. Any other seizure endangers the 
child by pressure upon the neck, and, moreover, is insecure. Traction 
is made horizontally till the chin is brought well under the pubic arch ; 
then by raising the handles the face, the vertex, and the occiput are 
successively swept over the perineum. 

Forceps to Breech. Forceps, while not well adapted to the breech, is a 
valuable measure in certain cases of this presentation. When the pelvic 
end of the foetal ovoid has so far engaged that a foot cannot be brought 
down, yet has not sunk deeply enough in the excavation to permit the 
successful use of finger or fillet, the forceps may be tried. The axis- 
traction instrument is to be preferred, especially in high operations. 
The best application is that of Ollivier : one blade resting over the 
sacrum and one ilium, the other over the posterior surface of the opposite 
thigh. 

Manual rotation is sometimes possible when the position is not pri- 
marily suitable for a satisfactory seizure. When the breech is fixed 
transversely in the pelvis, the blades may be placed over the trochanters. 
Application over the iliac crests is recommended by some writers, but 
these bony prominences are compressible, and the tips of the blades are 
liable to injure the abdomen. In all applications to the breech it is 
difficult so to regulate the grasp as to make the hold secure and at the 
same time to prevent injurious pressure. The amount of tractile force 
should be kept at a minimum by pulling only during the pains and by 
the help of abdominal pressure applied by an assistant over the fundus. 
If the child is dead a firm grasp is permissible. 

Forceps to After-coming Head. In all cases of breech extraction the 



696 



OBSTETRIC SURGERY. 



forceps should be in readiness for instant use in cases of difficulty in 
extracting the after-coming head. The forceps in head-last births, while 
seldom necessary, is the most effective of all methods of delivering the 
head. The application is attended with no difficulty. The body of the 
child should be held up over the abdomen of the mother and the blades 
passed beneath the foetal trunk (Fig. 405). 

Fig. 405. 




Extraction of the after-coming head with forceps. 

Head Separated from the Trunk. It may become necessary to ex- 
tract the detached head from the uterus after decapitation or when the 
head has been torn from the trunk and left behind through unskilful 
traction upon the trunk in breech births. Frequently, with the aid of 
suprapubic pressure, the delivery is possible without resort to instru- 
ments. In forceps as in manual extraction, the chin in such cases should 
first be brought down and so held during the delivery, to keep the long 
diameter of the head in the axis of the uterus. 



Axis-tractiox Forceps. 

An obvious disadvantage of the classical forceps is the fact that in 
pulling in line with the handles the tractile force is not applied in the 
parturient axis. The head as it is drawn down is dragged against the 
anterior soft parts of the birth-canal (Fig. 399). 

By Pajot's manoeuvre this fault in the ordinary forceps is obviated in 
part but not wholly, since it is impossible to estimate precisely the direc- 
tion of the pelvic axis. Several devices have been proposed with a view 
to accomplishing axis traction. Among these may be mentioned the 
forceps of Galabin, with the handles bent backward, Hubert's forceps, 
in which the traction is made at the end of a rigid arm projecting back- 
ward at a right angle from the shanks, and Poullet's forceps, in which 
the pull is applied by means of tapes passed through apertures in the 
blades. All these instruments are open to the objection that the line of 
pull is left to the judgment of the operator, and they do not, therefore, 
insure precision in the right line of traction. 



THE FORCEPS. 



697 



Another and perhaps a more serious defect in the common forceps is 
the fact that its rigid grasp interferes to a greater or less extent with 
the natural movements of the head. In this particular, as in the line of 
pull, it is iu high operations that the ordinary instrument is at its greatest 
disadvantage. This fault, like the first, loses much of its importance at 
the hands of a skilful operator, yet is by no means wholly obviated even 
by the most expert management. After the head has reached the pelvic 
floor the mechanism is less complex and its regulation more easily at 
command of the operator. 

In 1877 Tarnier, of Paris, gave to the profession an axis-traction for- 
ceps which, as since modified, has been widely adopted. In this instru- 
ment each arm, which does not differ essentially from the ordinary pattern, 
is provided with a slender traction-rod which is attached by a movable 
joint to the heel of the blade and terminates below near the lock. The- 
oretically the rods should pull from the centres of the blades, since trac- 
tion from these points would involve no directive action on the head. 
But to place the traction studs at the centre of the blade it would be 
necessary to insert in the fenestra a transverse bar, which would be likely 
to injure the head. The stud is, therefore, located at the heel of the 
blade. This construction, while not theoretically perfect, practically 
answers all requirements. The rod runs along the under edge of the 
shank, and when not in use is held in place by a, pin against which it 
rests at its lower end. After the blades are applied and the instrument 



Fig. 406. 




Tarnier' s axis-traction forceps. 



locked the necessary compression is maintained by means of a fixation 
screw attached to the handles. The use of the fixation screw, however, is 
not always necessary. The lower ends of the traction rods are released from 
the shanks and are locked to a traction handle. The latter consists of 
a single rod bent strongly backward and armed at its lower end with a 
cross-bar for convenience in pulling. The construction of the instru- 



698 



OBSTETRIC SURGERY. 



ment is such that when the traction rods are held about two-fifths of an 
inch away from the forceps shanks the line of pull will be in the axis of 
the blades, and, therefore, in that of the birth-canal. A movable joint at 
the cross-bar and the one at the attachment to the blades permit the 
utmost freedom of head movements. The blades when properly applied 
maintain their normal relation to the axis of the passages as the head 
descends. The application handles change their direction with the 
changing direction of the blades in the course of the descent, and thus 
serve as an index of the right line of traction. 

Lusk's axis-traction forceps differs from the Tarnier model mainly in 
being lighter. In the Simpson pattern the traction apparatus is attached 
to the ordinary Simpson forceps. Murray has made a special study of 
the principle of axis traction from a mathematical stand-point, and has 
enunciated a formula for the construction of the instrument. Reynolds 
and others have devised traction rods to be attached to ordinary forceps; 
but these appliances only approximately accomplish their object. The 
axis-traction forceps of the writer is constructed on the formula of Milne 
Murray, but is much lighter (Fig. 408). A model used for several years 
weighs, without traction rods and handle, only sixteen ounces, yet has 
proved equal to all requirements. 




Mechanics of axis-traction forceps. 

Pulling at the traction-handle in the direction indicated by the lower arrow, the line of traction is 

in the axis of the blades, as shown by the upper arrow. (Farabeuf and Varnier.) 

The superiority of axis-traction forceps over the simple instrument, as 
commonly accepted, depends upon two things: 1. Pulling as it does directly 
in the line of descent all the tractile force is utilized. 2. The blades being 
free to follow the natural movements of the head, the normal mechanism is 
not disturbed. Delivery is thus accomplished with the least possible 
amount of traction and with a minimum of maternal and foetal injuries. 
The facility with which the head may be brought down with axis-traction 



THE FORCEPS. 



699 



forceps is often in striking contrast with the difficulty frequently encoun- 
tered iu delivery with the classical instrument. Breus, however, denies 
that the value of the Tarnier forceps depends in any degree on the axis- 
traction feature, and attributes it solely to the movable joints of the trac- 



Fig. 408. 




Jewett's axis-traction forceps. 
K. Lock for attaching traction-handle to rods. 



tion rods and the consequent freedom of the head movements. His own 
instrument consists essentially of a simple forceps modified by the intro- 
duction of a movable joint between the blades and the shanks. A pair 
of rods rigidly attached to the blades and projecting in front of the 
shanks serves to indicate the position of the blades (Fig. 409). 



Fig. 409. 




Breus' Forceps. 

Murray and Xaegele claim the same advantage for axis-traction appa- 
ratus in low as in high operations. In the writer' s experience, pelvic-floor 
injuries have occurred more frequently when the delivery was completed 
with Tarnier' s than with the common forceps. The axis-traction instru- 
ment offers no advantage after the head has passed the inferior strait. 
Below this point the special tractors may best be disused and the delivery 
be managed as with simple forceps, or the latter be substituted. 

Operation. The blades are best applied with the patient in the usual 
dorsal recumbent position. For extraction she may lie on the back 
if the operation is conducted on a table; on a low bed she should 
be turned upon the left side. Walcher's position may be utilized in 
difficult extractions. After the forceps has been adjusted and locked, 
the application handles are grasped with one hand firmly enough barely 
to brinp; the blades in contact with the head. The fixation screw is then 



700 OBSTETRIC SURGERY. 

set to maintain the pressure thus obtained, but must not be used for com- 
pression, owing to the difficulty of correctly estimating the amount of 
force applied. The use of the screw, however, is not always necessary. 
When employed it should be released in the intervals between tractions. 

The pull is applied at the traction bar with one hand, while a finger of 
the other is held against the head to give warning should the blades begin 
to slip. Very rarely will it be necessary to use both hands for pulling. 
The traction rods must not be allowed to rest against the shanks of the 
forceps, but should constantly be held in a position just free from them. 
As the head descends the application handles move forward, and thus 
indicate the changing direction in which traction is to be made. 

When the head has been brought down to the pelvic floor the traction 
handle is detached and the delivery completed as with the ordinary for- 
ceps, or the classical instrument may be used if preferred. 



CHAPTER XXXII. 

VERSION. 

Veesiox may be defined as a manual operation by which the long 
axis of the foetal ovoid is wholly or partially inverted. Thus a cephalic 
may be substituted for a podalic presentation, or a podalic for a cephalic, 
or a transverse may be reduced to a longitudinal presentation. When 
the head is made to present, the operation is termed cephalic version ; 
when the foetus is so turned as to bring one or both feet into the birth- 
canal, it is called podalic version. The terms podalic and pelvic version 
are used interchangeably. 

Version may be accomplished in one of three ways : by external, 
internal, or combined external and internal manipulation. 

Indications for Cephalic Version. The indications for cephalic version 
are limited, since other than a head presentation is commonly due to 
some disproportion between the head and the pelvic inlet (Pinard). 

Transverse and breech presentations when seen before labor or during 
the first stage prior to rupture of the membranes justify an attempt 
at cephalic version. To be successful, the membranes must not have 
been broken, and the pelvis must be sufficiently ample to receive and 
permit the engagement of the cephalic pole. 

Indications for Podalic Version in Transverse Presentation. In normal 
pelves with the head presenting and the life of the mother or child 
threatened, if the head is not or can not be engaged, or the cervix is not 
sufficiently dilated to permit the use of forceps, podalic version is the 
operation of election. In certain cases of placenta prsevia one or both 
feet may be brought down to control hemorrhage. In prolapse of the 
cord, when the membranes are ruptured and the head has not entered 
the brim, attempts at reposition having failed, version may be done. 
In prolapse of one or both arms, or of an arm and a foot, podalic 
version is indicated. In head presentations when owing to malposition 
or other complication the head fails to engage at the superior strait, as 
in face or brow presentation, twins or irreducible occipito-posterior posi- 
tions or when proper flexion to secure engagement cannot be made ; in 
anencephalus and in the minor degrees of hydrocephalus ; in emer- 
gencies complicated with an unengaged head or an incompletely dilated 
cervix, as eclampsia, accidental hemorrhage, rupture of the uterus, 
embolism, and death of the mother, podalic version affords the most rapid 
means of delivery. 

Podalic version is indicated in simple flattened pelvis when the cou- 
jugata vera is not less than 8 cm. (3.15 inches), the head being of 
typical normal size ; and in all cases of equivalent disproportion between 
head and pelvis. 

Contraindications to Podalic Version are : impaction or firm engagement 

(701) 



702 OBSTETRIC SURGERY. 

of the presenting part ; tetanic contraction of the uterus with a well- 
developed ring of Bandl, appreciable two or more inches above the 
symphysis (Winckel) ; true conjugate below 8 cm. (3-J- inches) ; 
oblique contraction in which the inlet is encroached upon ; long-con- 
tinued dry labor ; cervix not dilated or dilatable. While the last two 
conditions do not positively prohibit the performance of version, the 
difficulties and dangers of the operation are so increased that the pro- 
cedure is hardly justifiable. 

Conditions Favorable to the Successful Performance of Version are : exact 
diagnosis ; ample pelvic capacity, with approximate knowledge of the 
relative size of the child and pelvis ; thin and flexible abdominal walls ; 
and the presence of the whole or part of the amniotic fluid. 

Dangers of Version. To the Mother. In external and bipolar version 
the dangers are insignificant. In internal version the woman is subject 
to the increased risks of possible uterine rupture, sepsis, hemorrhage, 
shock, and extensive lacerations of the cervix and pelvic floor. 

The Child is exposed by the internal podalic method to injury or death 
from fractures of the humerus and femur, compression of the spine, 
and asphyxia during its passage through the birth-canal. 

While under modern methods of diagnosis the field of version has 
been narrowed for the expert by traction forceps, symphyseotomy, and 
elective Csesarean section, it will always remain a valuable procedure 
for the general practitioner in emergencies necessitating rapid delivery 
in the presence of an unengaged head, and when proper assistance and 
appliances for the performance of its alternatives are not at his imme- 
diate command. 

External Version. Version by external manipulation is employed to 
convert a breech into a head presentation or to correct transverse pres- 
entation. It is the simplest and safest method of turning, and is too 
seldom practised, since few physicians become skilled in abdominal 
palpation. A positive diagnosis is essential before version is attempted 
by any method. Pelvic or podalic version by external manipulation 
is not always practicable. Cephalic version by the external method is 
frequently possible, and has been advocated in breech presentations 
by recent writers when seen before or at the beginning of labor. The 
presence of the liquor amnii, thin, lax abdominal walls, and an ample 
pelvis are prerequisites. The method is free from all danger of 
septic infection. Objections which have been urged against the con- 
version of breech presentations into head cases are : First. In primi- 
parae it is generally impossible without anaesthesia to perform fcetal 
evolution, because of the resistance of the maternal soft parts. Second. 
Foetal accommodation will commonly cause the breech to return to the 
superior strait, owing to the continued existence of one of the four gen- 
eral causes of malpresentation and malposition, i. e., small pelvis, large 
head, excessive liquor amnii, or small child. In multiparas little is to 
be gained by the substitution of the head for the breech, as these cases 
usually terminate favorably, if properly managed, to both mother and 
child. On the other hand, substitution of the breech for the head by ex- 
ternal version may be advantageous in oblique contraction of the pelvis 
when the antero-posterior diameter exceeds 3f- (9.51 cm.) inches, since it 
enables the operator to direct the large occipital pole of the head toward 



VERSION. 



703 



the most roomy side of the pelvis ; in transverse presentations ; in 
slightly flattened pelves ; and in abnormal presentation of the placenta. 

Coxtkaixdicatioxs to External Version. This operation can- 
not be effected when the presenting part has sunk deep in the pelvis, or 
when the amniotic fluid is scant or has already drained away, when the 
waters are excessive, or in the presence of a macerated foetus or twin 
pregnancy. It is seldom practicable after the onset of labor. 

Technique. Preliminary Measures. The position and size of the 
child are determined by abdominal palpation. The size of the pelvis 
is estimated. The bladder and the rectum are emptied. Irregular or 
spasmodic contractions of the uterus are controlled with an opium sup- 



FlG. 410. 




External version. 



pository, if labor has already begun. The woman is placed in the dorsal 
position, with the head and shoulders elevated, the legs and thighs 
slightly flexed, and the knees apart. Anaesthesia is seldom neces- 
sary. 

A hand is now placed on each pole of the foetal ovoid, and by steady 
pressure the head is carried in the direction toward which the occiput 
points, while the breech is pushed toward the feet. This manipulation 
is checked from time to time by uterine contractions. Whatever gain 
has been made in the evolution must be held carefully until the uterus 
again relaxes, when the effort is continued until a favorable longitu- 
dinal presentation is obtained. When either the head or the breech is 
brought over the brim it should be made to engage, for until the pre- 
senting part has entered the superior strait the version is not complete. 



704 OBSTETRIC SURGERY. 

This is usually accomplished when external version is made after labor 
has begun and regular uterine contractions are fully established, or by 
rupture of the membranes when the version is made during the latter 
part of the first stage. Under such conditions the head or breech may 
be crowded into the pelvis by suprapubic pressure w T ith the patient in 
"YValcher's position. 

When the presenting part cannot be made to engage, the longitudinal 
relation of the foetus must be retained by the application of pads and 
binder until labor is established, as the causes which had produced the 
primary malpresentation tend to reproduce it. In certain cases reten- 
tion of the foetus in the desired position can be maintained only by 
rupture of the membranes, an undesirable procedure because of the con- 
sequent dry labor. 

Bipolar Version was perfected by Braxton-Hicks, who demonstrated 
the practicability of causing the relation of the long axis of the foetal 
ovoid to conform with that of the uterus by combined external and 
internal manipulation. In Hicks's method the internal fingers do not 
pass beyond the presenting part. 

The advantages of this method are : that it may be accomplished 
through a dilatation of the cervix that will admit but two fingers, 
during the first stage of labor, before the membranes have ruptured, 
or after rupture before the waters have drained away. Done under 
aseptic precautions there is less danger of infecting the uterus than in 
the internal method, as the fingers never penetrate the deeper parts 
of the womb. Shock, traumatism, and danger of injury to the foetus 
are diminished. Separation of the placenta and prolapse of the cord 
are preventable accidents. 

Indications foe Bipolab Version. — Bipolar version is indicated 
in brow presentations when attempts at flexion and engagement have 
failed ; in occipito-posterior positions of the vertex when postural and 
manual methods have not succeeded in bringing the head into the brim. 
In cross-births and in prolapse of the cord with but slight cervical dila- 
tation, before the waters have escaped, bipolar version may be tried. In 
placenta previa podalic version by this method brings the breech within 
the cervix much earlier than is possible by the internal method, secur- 
ing compression of the placenta and arresting hemorrhage. In all of 
the foregoing conditions bipolar turning should be the operation of 
election. 

Method of Performance. Strict asepsis is imperative. After 
the bladder and rectum have been emptied the patient is placed across 
the bed or upon a table, in the dorsal recumbent position, with the thighs 
flexed on the abdomen, and the vulva, vagina, inner surfaces of the 
thighs, and the abdominal wall are rendered aseptic. Anaesthesia facili- 
tates the manipulation. 

Before operating the diagnosis should be confirmed under narcosis. 
Care must be taken not to rupture the membranes, as the presence of 
the amniotic fluid favors easy evolution of the foetus. 

AVhen a cephalic version is to be made by this method, Hicks's clear 
and concise description w T ill perhaps serve as the best guide : " Intro- 
duce the left hand into the vagina, as in podalic version, and place the 
right hand on the outside of the abdomen, in order to make out the 



VERSION. 



705 



position of the foetus and the direction of its head and feet. Should 
the shoulder present, push it with one or two fingers in the direction 
of the feet. At the same time pressure with the other hand should 
be exerted on the cephalic end of the child. This will bring the head 
down to the os ; then let the head be received on the tips of the two 
inside lingers. The head will play like a ball between the two hands ; 
it will be under their command, and can be placed in almost any part 
of the uterus at will ; let the head then be placed over the os, taking 
care to rectify any tendency to face presentation. It is well, if the 
breech will not rise to the fundus readily, after the head is fairly in 
the os, to withdraw the hand from the vagina and with it press the 
breech from the exterior. The hand which is gently retaining the 
head from the outside should continue there for some little time, till 



Fig. 411. 




First step in bipolar podalic version. The hand is in the vagina, and the two fingers through 
the cervix displace the head, while the external hand carries the breech toward the side on which 
the feet lie. 

the pains have insured the retention of the child in its new position 
and the adaptation of the uterine walls to its new form. Should the 
membranes be perfect, it is advisable to rupture them as soon as the 
head is at the os uteri ; during and after the escape of the liquor 
amnii the head will move easily into its proper position." The pro- 
cedure which has been quoted is so simple that there can be no objec- 
tion to its trial, for if it fails podalic version may be done without 
removing the hand from the vagina. 

Podalic version by this method finds more general application. The 
technique may be described as follows : one hand is passed into the 
vagina and two fingers through the cervix to displace the presenting 
part (the head), while the other hand is placed on the outside of the 
abdomen on the podalic pole. The choice of hands is of some impor- 
tance. If the occiput is lying to the left, the use of the left hand has 

45 



706 



OBSTETRIC SURGERY. 



an advantage ; while if the occiput is to the right, the right hand will 
more easily displace it into the iliac fossa. With the external hand the 
breech is pushed toward the side on which the feet lie, while the internal 
hand tosses the head out of the excavation into the iliac fossa toward 
which the occiput points. As each successive part of the foetus presents, 
it is tossed into the iliac fossa, while the external hand carries the breech 
into the lower uterine segment until a knee is brought within reach. 
The membranes are now ruptured and a foot brought down into the 
vagina. A podalic version is never complete until the breech is 
engaged. 

It is well to make sufficient traction on the presenting leg to bring 
the knee to the vulva ; when this has been accomplished it is evident 



Fig. 412. 




Second step in bipolar podalic version. 

that the breech has entered the brim. When the evolution is complete 
the case may be left to terminate unaided as a pelvic presentation, unless 
need for rapid delivery exists. 

Internal Version. In this method of turning the hand of the operator 
is passed into the uterus until a foot or both feet can be grasped and 
brought down through the cervix. This is the most effective and most 
commonly employed method of version. 

Indications for Internal Version. Many of the indications 
have already been mentioned under the general considerations for version. 
Chief among these are conditions of the mother or child calling for 



VERSION. 



707 



prompt delivery, as eclampsia, placenta praevia, accidental hemorrhage, 
threatened or sadden maternal death, and prolapsus funis. In malposi- 
tions of the head, when attempts at flexion and engagement of the 
vertex have failed, internal podalic version may succeed when the con- 
jugata vera is above 8 cm. (3.15 inches). The head may then be 
brought down through the superior strait by its smallest diameters. 
The head enters the brim as an inverted wedge. 

Daggers and Contraindications. This operation should not be 
attempted before the cervix is fully dilated or dilatable or easily passable 
for the head without injury. 

As the hand is passed deeply into the uterus, the woman is exposed to 
an increased liability to sepsis and to possible uterine rupture, owing to 



Fig. 413. 




Third step in (bipolar) podalic version. 



the additional bulk of the uterine contents. Considerable shock is 
occasioned by the operation, and too precipitate delivery may be followed 
by lacerations and post-partum hemorrhage. This operation should 
never be done in a tetanic uterus with a high and well-developed 
retraction-ring, nor when the head is firmly impacted in the pelvis. 

The Advantages are the speed and facility with which delivery may 
be accomplished, owing to the complete control which it affords of the 
foetus and its evolution. 

Method of Operating. Inasmuch as internal combined version 
has the broadest application and requires the introduction of the whole 



708 



OBSTETRIC SURGERY. 



hand and a part of the forearm into the uterus, it is necessary to impress 
the reader with the importance of observing the strictest aseptic technique. 
As internal version is most frequently performed after the membranes 
have ruptured and the uterus has closed down around the child , surgical 
anaesthesia will be useful by relaxing the uterus and contributing to the 
safety and success of the operation. This may be induced either by 
chloroform or ether, depending on the experience of the operator. 
Chloroform has, we believe, the advantage, as it relaxes the uterus 
sufficiently to allow the manipulations necessary to the evolution of the 

Fig. 414. 




First step. Right dorso-posterior with prolapsed arm. A noose is placed on the presenting wrist 
to facilitate subsequent extraction. (Farabeuf and Varnier.) 



child, while its effect is so transient as not to produce secondary uterine 
relaxation and hemorrhage. During the past year spinal anaesthesia 
with cocaine by subarachnoid injection has been employed in obstetrics 
by Marx and others, with most encouraging results. The safety of the 
latter procedure has not been sufficiently proved for us to advocate its 
general adoption in the performance of version. 

After emptying both bladder and rectum the exact position of the 
foetus must be mapped out carefully and the external genitals be 
made thoroughly sterile. The hair about the vulva is clipped with 



VERSION. 



709 



scissors and the pudendum scrubbed with soap and water, while the 
patient is being anaesthetized ; the soap is then rinsed off with sterile 
water and the parts bathed with an antiseptic, preferably with a 1 or 2 
per cent, solution of lysol, because of its lubricating properties. An 
ante-partum vaginal douche is unnecessary except in the presence of a 
purulent discharge from the vagina. The patient is placed across the 
bed or on a table in the dorsal recumbent posture, with the thighs flexed 
on the abdomen and the knees held apart by an assistant or maintained 
in position by the Robb or Bissell leg-holder or a Dickinson sheet sling. 
The hand is introduced into the vagina until the cervix is reached. If 
the cervix is not dilated or passable to the hand, its dilatation is at once 
begun. This may be accomplished manually as described by Harris ; or 
should a constricting ring exist around the os which does not yield to 



Fig. 41; 




Second step. Grasping the upper foot. (Farabeuf and Varnier.) 

the finger, it may be wise, where it is necessary to expedite delivery, to 
make six or eight nicks into the hardened ring of the cervix, distributed 
throughout its circumference. Multiple incisions made on these lines 
will facilitate dilatation and tend to prevent extensive laceration of the 
cervix. If the waters have not escaped, care must be taken to pre- 
serve the membranes during dilatation. When the os is fully dilated 
the hand is introduced through the cervix, and the membranes, if still 
intact, are ruptured. In longitudinal presentation advantage will be 
gained by using the hand, the palm of which will confront the child's 
abdomen. The hand is passed deeply into the uterus between the pains. 
If a contraction of the uterus takes place, the hand must be flattened 
out and held quiet until the pain has subsided. If the head is in the 
way, it is pushed to one side in the direction toward which the occiput 



710 



OBSTETRIC SURGERY. 



points, and the hand passed along until a foot is grasped. Before 
making traction on the foot the operator should make sure that the cord 
is not looped over the leg. If it is, it must first be disengaged. " As 
traction is made on the leg within the grasp of the hand the greatest 
possible aid may be derived from manipulating the head of the infant 
toward the fundus with the other hand externally placed on the surface " 
(Simpson). As the foot is drawn into the vagina and the knee presents 




Third step. Grasping the foot and making traction. The arm ascends as the evolution is com- 
pleted. (Farabeuf and Varxier.) 



at the vulva the head ascends into the fundus and the version is com- 
pleted. Unless there is some indication for immediate delivery, all 
traction should cease and the patient be allowed to expel the child 
spontaneously until the umbilicus is born. This secures a greater dila- 
tation of the cervical canal and produces a paresis of the circular muscle 
of the cervix w r hich facilitates extraction of the shoulders and the after- 
coming head. 



VERSION. 711 

In transverse presentation the method already described may be fol- 
lowed ; but as the head is in one or the other iliac fossa the hand may 
be passed directly into the uterus and a foot sought at once. From 
that moment the operator is master of the situation. 

In shoulder presentation where the arm has become prolapsed but has 
not become impacted, it may be replaced without difficulty and the ver- 
sion proceeded with ; yet reposition of the arm is not necessary, for it 
will be drawn out of the vagina as the foetus assumes a longitudinal 
presentation. An expedient which is found useful in the subsequent 
extraction which commonly follows podalic version is to fasten a loop 
of tape or a piece of roller bandage around the wrist before the arm is 
pushed up or drawn up by the evolution of the child ; in this way at 
least one arm may be prevented from becoming extended during sub- 
sequent manipulation. 

Impacted shoulder presentations afford the obstetrician ample oppor- 
tunity for a display of his manual dexterity. In such cases the arm 
has become prolapsed and long-continued uterine contraction has caused 
the shoulder and thorax to become wedged into the pelvis. In the 
management of such a malpresentation the thorax must be carried up 
above the brim and displaced into the iliac fossa before attention is 
given to the prolapsed arm. This procedure is not only difficult, 
but dangerous as well, as uterine rupture is almost certain to result 
unless the greatest care is observed ; a tetanic uterus with a more 
or less perfectly developed retraction-ring is an almost constant 
complication of impacted shoulder cases. This means that version, 
if made, must be done in the thinned-out lower segment of the 
womb. 

To relieve such an impaction surgical anaesthesia is required. 

If, after making well-directed pressure from below with the hand 
which corresponds to the prolapsed arm, while firm external counter- 
pressure steadies the fundus, the impaction cannot be relieved, embry- 
otomy affords the best means of terminating the delivery. In another 
part of this chapter the relative value of version, craniotomy, and sym- 
physeotomy will be considered in detail. Should it be possible to reduce 
the impaction of the shoulder and thorax, considerable difficulty may 
be experienced in completing the version, owing to the tetanic condition 
of the uterus which prevents the head from ascending to the fundus. 
Fcetal evolution may be expedited by the use of the following sugges- 
tion. For illustration, let us consider a left scapular anterior with a 
prolapsed arm and impacted thorax. Ether or chloroform narcosis 
will at least secure partial relaxation of the uterus. The right hand 
of the operator is now placed in the fcetal axilla just in front of the 
axillary line, and pressure is made from below upward and the shoulder 
and thorax pushed toward the mother's right iliac fossa. During this 
upward pressure the fundus must be held firmly by an assistant. As 
the shoulder is displaced enough room is gained to allow the hand to 
pass through the brim and into the uterus to seek a foot ; the near foot 
should have the preference in this position. "When the foot is grasped, 
it may be pulled into the vagina without causing the evolution of the 
child, as the tight uterus firmly holds the foetus with its long axis trans- 
verse to that of the mother. If a loop of roller bandage is now slipped 



12 



OBSTETRIC SURGERY. 



over the foot in the vagina, traction may be made on it while the other 
hand of the operator is passed into the vagina alongside of the leg to 
pnsh each successive foetal part toward the fundus as it is forced down 
by the uterus into the brim ; in this way the head rapidly ascends and 
a longitudinal presentation is secured. The force is practically applied 
to both poles of the foetus at once ; i. e., upward pressure being applied 
with the left hand in the vagina, while traction is made at the same 

Fig. 417. 




Combined internal version. Applying force to both poles of the foetus at once. 



time on the leg through the use of the bandage traction noose with the 
right hand. 

The Influence of Posture in Facilitating Version. The dorsal position 
with the hips elevated and well over the edge of the bed or table, the 
thighs flexed on the abdomen, and the knees widely separated, gives 
the operator the most direct and ready access to the fundus. During 
extraction, in bringing; the after-coming head into the brim, additional 
space may be gained in the true conjugate by extending the thighs over 
the edge of the table (Walcher's position). This lowers the pubes and 
increases the antero-posterior diameter at the brim by J to J inch (.83 
to 1.26 cm.). The knees must be kept well separated, so as not to inter- 
fere with the extraction. 



VEBSIOX. 713 

Version in dorso-posterior positions and in cases of pendulous abdo- 
men may be facilitated by placing the patient on the side, in the latero- 
prone posture. She should turn on the side on which that pole of the foetus 
lies which is to be brought down ; e.g., in a left scapulo-posterior the 
right latero-prone posture, and vice versa in left positions. When oper- 
ating with the patient in this posture advantage is gained by slipping 
/the hand beneath the child along the lateral aspect of the uterus. The 
right hand is employed when the patient is lying on her right side, and 
the left when she is lying on her left. 

Either the knee-elbow or the Trendelenburg posture may be utilized 
, with advantage when operating after the waters have drained away and 
the uterus holds the presenting part snugly against the inlet. In some 
impacted shoulder cases the Trendelenburg posture in conjunction with 
ether narcosis makes it possible to relieve an impaction in which repeated 
efforts with anesthesia alone have failed. While theoretically the knee- 
breast position has many advantages over the ones referred to, it is dif- 
ficult to use it in conjunction with anaesthesia ; on the other hand, the 
Trendelenburg position has all the advantages of the knee-breast, and, 
in addition, affords greater facility of narcosis. Mensinga has advo- 
cated the prone position during version. The superiority claimed for 
this posture is the same as may be had from the employment of any of 
those already described when the exact position of the child and the 
condition of the uterus have been fully determined. 

The choice of hand in the performance of version is largely a matter 
of personal preference. Scientifically, it is dependent on the position 
of the foetus and the posture in which the woman is lying. One will 
naturally use the hand which will pass most easily to the leg to be 
grasped ; this presupposes accurate diagnosis. In cephalic presentation, 
wdien the patient is lying across the bed, the hand the palm of w 7 hich 
will pass over the child's abdomen may be employed ; while in trans- 
verse cases the hand which corresponds to the side on which the breech 
lies has the advantage. These rules apply also when the patient is in 
either the knee-breast or Trendelenburg posture. Many operators pre- 
fer to use the left hand for all versions, as the right hand is usually 
more dexterous in extraction. 

The choice of foot is another question that has given rise to much 
discussion. In cephalic presentations there is little or no advantage in 
choosing one foot over the other, as traction upon either foot will rotate 
the dorsum to the front. In transverse cases it is wise to seize the knee 
or leg which will maintain a dorso-anterior position or will convert a 
dorso-posterior into a dorso-anterior ; i. e., take the further leg in dorso- 
posteriors, and the nearer leg when the foetal dorsum is to the mother's 
abdominal wall (Hart). The observance of this rule will facilitate 
anterior rotation during the subsequent extraction. 

According to Nagel, it is immaterial which foot is grasped so long as 
the leg which has been seized is brought forward behind the pubes, and 
as gradual traction is made between the pains the child's trunk is rotated 
toward the front 

When immediate and rapid delivery is to follow version the rule is 
to grasp both feet. This is to be particularly advocated in the pres- 
ence of a premature, dead, or macerated foetus. How the leg shall be 



714 OBSTETRIC SURGERY. 

grasped is another practical consideration which merits description. 
With the back of the hand toward the uterine wall the foot may be 
seized between the index and middle fingers of the internal hand, so 
that the fingers are folded over the os calcis, the dorsum of the foot 
with the ankle falling between them. 

When seizing both feet the middle finger is passed between the 
child's ankles, and the other fingers are folded so as to surround both 
ankles. 

Maintenance of the proper line of traction contributes to success in 
version. With the patient on a table traction in the axis of the inlet 
is possible, and the external hand may simultaneously operate through 
the abdominal wall to carry the opposite pole toward the fundus. 
Traction in the axis of the plane of the brim, or more properly in a 
downward and backward direction, is usually continued until the knee 
presents at the vulva, which indicates that the version is complete, 
when we pass from version to extraction. 

The dangers to the mother from version, already mentioned in this 
paper, are septic infection, shock, rupture of the uterus, and lacerations 
of the soft parts. In order to protect the woman from these accidents 
a conscientious aseptic technique is requisite. The hands of the operator 
must be stripped of rings, the nails cut and cleaned dry, and the hands 
and forearms, including the elbow, thoroughly scrubbed with soap and 
water ; ten minutes is not too much time for this detail. The hands and 
forearms are then rinsed in sterile or running water, and when possible 
immersed in alcohol to free them from all fat and soap ; finally they are 
bathed in a solution of corrosive sublimate, creolin, formalin, or lysol ; 
the latter possesses lubricating as well as strong antiseptic properties. 
For still further security the obstetrician should, if possible, wear rubber 
gloves with gauntlets. 

Disinfection of the external genitals and immediate surroundings must 
be carried out after the bladder and rectum have been emptied. The 
hair should be clipped from about the vulva and the pudendum scrubbed 
with soap and water ; the cleansing should include the abdomen and 
the inner surfaces of the thighs. After rinsing off the surplus lather 
with sterile water all of the cleansed surfaces are washed with the anti- 
septic solution. 

If the reaction of the vaginal secretion is acid, no preliminary douch- 
ing is necessary ; on the other hand, if the vaginal secretion is purulent 
or alkaline in reaction, the passage must be thoroughly cleansed with 
soap and water, followed by an antiseptic douche. If the membranes 
have ruptured and the waters drained away, or considerable time has 
been spent with the hand in the uterus, or the placenta has been removed 
manually, a post-partum intra-uterine douche may be given. 

Shock may be guarded against by the timely use of strychnine, minute 
doses of morphine, and the introduction of a hot saline solution into the 
colon, or, where more prompt action is needed, directly into the cellular 
tissues, behind the mammary gland, or into a vein. 

Version is especially dangerous when done after the amniotic fluid 
has drained away and a retraction-ring has developed. Under such 
conditions the uterus is in a state of tetanic spasm, the greater part of 
the child being in the thinned-out lower segment of the womb. 



VERSION. 715 

Xeglected shoulder presentations constitute a most dangerous class of 
cases, and when a retraction-ring is appreciable between the pubes and 
umbilicus, with the patient anaesthetized, craniotomy or decapitation 
should be elected in lieu of version, to insure the best interests of the 
mother. 

It is often possible to secure complete relaxation of the uterus under 
chloroform, and then with care and patience to succeed in bringing 
about the evolution of the child. The employment of the Trendelenburg 
posture adds greatly to the facility with which this may be done. Firm 
counterpressure must be made on the fundus to prevent the uterus 
being torn from its vaginal attachments during the upward pressure 
necessary to introduce the hand past the presenting part. After getting 
the hand in the uterus, if it is found that the child is dead, or that the 
lower segment is excessively thinned, or that the foetus is hydrocephalic 
or a monster, version should not be made. 

The injuries and lacerations to the soft parts following version and 
extraction consist of tears of the cervix, vagina, and pelvic floor; these 
are produced by rapid delivery through undilated passages. When time 
permits, a spontaneous birth after version may prevent many of these 
injuries. 

Prompt suturing of the perineal and vaginal tears protects the patient 
against sepsis. It is unwise to suture cervical lacerations unless hemor- 
rhage is of sufficient moment to demand it. 

Version and extraction through partially dilated passages expose the 
infant to the danger of asphyxiation. The operator must be prepared 
to combat this mishap, and have at hand means of resuscitation, which 
may be employed without delay. Two haemostatic forceps will be 
found useful to clamp the cord, two small bath-tubs, one containing 
hot and the other cold water, ready for alternate immersion of the child, 
and a warm blanket to receive it, are among the ordinary requisites of 
the lying-in chamber. Many children may be saved by the prompt 
institution of one of the methods of artificial respiration. Schultze's 
method, or mouth-to-mouth insufflation, is to be given the preference. 
In using Schultze's method expiration should be the first act, as in this 
way the respiratory passages are emptied of inspired mucus ; it is also 
important to prevent chilling of the body by frequent immersion in 
warm water. 

Shall Immediate Delivery Follow Version ? As a rule, the two opera- 
tions should be separated and spontaneous delivery encouraged. This 
must depend, however, upon the conditions in the particular case. If 
after cephalic version the head becomes flexed and engages, the labor 
may be left to itself or be terminated by forceps should the condition of 
either mother or child call for prompt extraction. On the other hand, 
if the head will not enter the brim as either a vertex or a face, podalic 
version is available. 

To estimate the relative proportion between a flexed head and the 
pelvis in a given case, the patient should be in Walcher's position 
under an anaesthetic and the bladder and rectum empty. The sterile 
hand is then introduced into the vagina, and the head grasped and held 
in flexion, while the external hand attempts to crowd the flexed head 
into the pelvis. The axis-traction forceps will occasionally succeed in 



716 



OBSTETRIC SURGERY. 



bringing the head into the superior strait when other methods have 
failed. If the existence of positive disproportion has been demonstrated 
and the conjugata vera is not below 3.15 inches, podalic version and 
extraction of the after-coming head may be successful, as the diameters 
of the cranial vault diminish by compression as the head passes through 
the pelvis. 

Extraction after podalic version may be immediate or deliberate, 
depending on the existing conditions in the particular case. 

Accidental hemorrhage, placenta prsevia, eclampsia, and prolapse of 
the cord in transverse presentations may demand rapid delivery ; but 
the degree of dilatation should largely govern the election of the rapid 

Fig. 418. 




Delivery of the first arm. Carrying the arm past the head. 

or deliberate method. The writer is of the belief that one of the most 
fruitful causes of stillbirths is the habit of many practitioners to termi- 
nate labor immediately upon turning the fcetas, before complete canaliza- 
tion of the passages. Extraction under such conditions may be com- 
plicated by fractures of the femora and humeri, and by asphyxia of the 
infant. In one instance the writer saw the head severed from the body 
during an attempt at rapid delivery through incompletely dilated pas- 
sages. 

When version has been completed the operator should note the foetal 
heart-rate and the general condition of the mother before determining 
the advisability of immediate or deliberate delivery. Wherever pos- 
sible without compromising the interests of either, spontaneous delivery 
should be elected. The physician should be ready with sterilized hands 
and instruments to terminate labor at once in case of impending danger 
to either mother or child. 

Xo discussion of version would be complete without briefly consider- 



VERSIOX. 



717 



ing the methods of extraction which may accomplish rapid and safe 
delivery. While we have attempted to separate the two operations, 
each having its indications and limitations, the one follows the other 
with such frequency that many have come to assume that version includes 
extraction. 

To perform rapid extraction, the patient must be brought across the 
bed or placed in the lithotomy position on a table. An anaesthetic is 
not always necessary ; but if one has been employed during the version, 
it may be continued until the extraction is completed. When the foot 
emerges from the vulva it is wrapped in a warm towel and grasped by 
the operator, and traction is made in a downward and backward direc- 



Fig. 419 







^R 




wyV^SBII 


\ 


^PULJ^ 


\ 


^^feosSPkV 









Delivery of the first posterior arm. 



tion, in the axis of the brim, while an assistant makes Avell-directed 
pressure on the child's head to maintain flexion. This external pressure 
must be continued throughout the operation. As the buttocks emerge 
from the vulva the index and middle fingers of the hand which corre- 
sponds to the flexed thigh are slipped into the groin and the hip lifted 
out ; the pelvis is then grasped with both hands and traction continued, 
while the body is rotated into the oblique diameter of the pelvis, keeping 
the back well to the front. When the body is out it is carried upward 
over the pubes to disengage the flexed thigh and make it clear the 
vulva. 

As the shoulders engage at the superior strait the posterior shoulder 
strikes the pelvic floor first, and is shunted downward and inward 
until it is within easy reach. The rear arm therefore is more easily lib- 
erated. If the assistant has succeeded in maintaining flexion by supra- 
pubic pressure, the arm may be found flexed on the chest. It is common 
experience, however, that one or both arms slip up and become ex- 
tended. To liberate the posterior arm, the feet are seized, and while 



718 OBSTETRIC SURGERY. 

making traction the body is carried over to the side opposite the occiput. 
This causes the posterior shoulder to come into the median line within 
reach, the fingers of the free hand are passed along the dorsum to the shoul- 
der and up the humerus to the elbow-bend, which is drawn downward, 
flexing the forearm across the face and chest of the child (Fig. 419). 

To deliver the second arm, seize the trunk with both hands and push 
it up in the axis of the brim, to release the extended arm from the grasp 
of the pelvis, and at the same time rotate the body so as to bring the 
extended arm to the rear. This rotation may be assisted materially by 
grasping the delivered posterior shoulder and using it as a rotator. 
When the second arm has been brought to the sacral side the legs and 
trunk are carried to the opposite side, while the free hand sweeps the 
second arm and forearm across the chest (Fig. 420). 

Fig. 420. 




Delivery of the second arm, using the delivered arm as a rotator. 

When the arms have been delivered there is usually little time to 
extract the head ; this may be done either manually or instrumentally. 
The body is wrapped in a warm towel and laid upon the forearm of the 
operator, while the hand is passed into the vagina along the sacrum until 
two fingers can be hooked into the canine fossae or the mouth, to main- 
tain flexion and keep the long axis of the head in the oblique diameter 
of the pelvis. If the head has not engaged, suprapubic pressure with 
the closed hand may force the head into the brim. As the head reaches 
the pelvic floor traction is made by two fingers placed astride of the neck, 
and the body is carried upward and forward over the maternal pubes 
(Fig. 421). 

In flattened pelves care must be taken to rotate the long axis of the 
child's head into the transverse diameter of the brim, and to have the 
patient in Walcher's position, in order to facilitate its engagement. 

The management of the cord during extraction is of primary impor- 
tance. When the breech has been delivered the cord should be pulled 
down and its pulsation noted ; in case of short cord it should be secured 



VERSION. 



719 



between two artery-clamps and cut. When it is possible the cord should 
be placed in that part of the pelvis in which it will have the most room ; 
this is generally in the space opposite the sacro-iliac joint which is not 
occupied during the passage of the head ; i. e., if the head is coming 
through in the right oblique diameter, the cord will be out of danger 
if it is placed opposite the left iliosacral joint. 

Delivery of the after-coming head may be accomplished without 
difficulty, except in the presence of a large head or a contracted pelvis, 
if the steps of the mechanism are kept constantly in mind ; i. e., to 
engage the head, it must be flexed and rotated into one or the other of 
the oblique diameters at the brim. Rotation may be aided by manipu- 

FlG. 421. 




The Smellie-Veit method of extracting the after-coming head, augmented by suprapubic pressure. 



lation through the abdominal wall with the external hand. The forceps 
should always be ready to terminate delivery in case of failure with 
manual methods. 

Extensive lacerations of the pelvic floor may be avoided if, after the 
mouth is delivered, time is taken to stretch the posterior segment of 
Hart, by holding the head before letting the suboccipito-frontal and 
suboccipito-bregmatic diameters pass through the vulva. Notwithstand- 
ing the employment of skill and care, rapid extraction of the foetus at 
full term is rarely accomplished without extensive laceration of the 
maternal soft parts. These injuries, if the mother's condition is such 
as to warrant further procedure, should immediately be repaired. The 
presence of shock or the want of proper assistance and aseptic suture- 
material should postpone restoration ; yet bleeding points that may give 



720 



OBSTETRIC SURGERY. 



troublesome hemorrhage are to be secured at once. Primary suture of 
tears in the cervix is of doubtful value in private practice ; only when 
the rent has severed the circular artery is suture positively indicated. 

Internal version followed by rapid extraction exposes the woman to 
the possibility of partial or complete separation of the placenta ante 
partum, which complicates the delivery with more or less hemorrhage. 
Even when no separation of the placenta has taken place immediate 
and rapid delivery increases the tendency to post-partum hemorrhage, 
since the uterus is not given time during the second stage for proper 
retraction and rearrangement of its fibres, such as take place when the 
expulsion is spontaneous. Upon delivery of the child the uterus must 
be grasped through the abdominal wall and stimulated to contraction. 
If it does not promptly retract and all bleeding cease, manual expression 







Fig. 422. 








^pp^ 




>s. 




f_?r 






k \. 






^S 


\^ 








A^\5 


i^ i 


H 


Si 



The Wiegand-Martin method of extracting the after-coming head. 



of the after-birth will conserve the best interests of the mother. Every 
ounce of blood lost increases the shock. 

When turning and extraction have been done for placenta prsevia or 
accidental hemorrhage, an intra-uterine tamponade of iodoform gauze 
stimulates the uterus to contraction and maintains retraction, safe- 
guarding the patient against further loss of blood, and by securing a 
tight uterus tends to fortify her against sepsis. The hypodermic use of 
strychnine over the womb in doses of y 1 - grain, repeated every two hours 
for three doses, corrects any tendency to relaxation. The effect of 
strychnine is superior to that of ergot, as it establishes a steadier and 
less spasmodic contraction of the uterine muscle. 

The complications of version, made so much of by some writers, are 
chiefly encountered when the operation is badly chosen. "When the 
diagnosis of position has been made, the indications and contraindica- 
tions thoroughly considered, and due care is exercised in its performance, 



VERSION. 721 

rupture of the uterus and separation of the womb from its vaginal 
attachments will be less common sequelae than a perusal of the literature 
would lead us to suppose. Unusual and complex presentations of the 
foetus, such as a transverse with prolapsed arm and foot, or twins lying 
crosswise in the uterus, may seriously embarrass the operator ; but with 
the proper appreciation of existing conditions and by patient and per- 
sistent work under complete narcosis these complications may be over- 
come and a longitudinal presentation be substituted. 

The Influence of Ventro-fixation and Vagino-fixation upon Version. 
Since these two operations have been practised for the correction of 
retrodisplacements of the uterus, many labors taking place in uteri 
firmly fixed to either the abdomen or vagina have been complicated by 
malpresentations of the foetus. The posterior wall of the uterus is 
subjected to extreme dilatation at the expense of its muscular strength, 
as the anterior wall which is fixed by adhesions does not participate in 
the uterine growth. Version in a uterus that is almost wholly developed 
from its posterior segment is fraught with danger of rupture. In such 
cases considerable difficulty has been experienced in getting the present- 
ing part to engage when pregnancy has occurred. 

When malpositions exist which necessitate turning advantage will be 
gained if the operation is done early, by the bipolar method, before the 
membranes have ruptured. When the waters have drained away ver- 
sion can be most satisfactorily made with the patient in the latero-prone 
posture. 

The Relative Value of Version, Forceps, and Symphyseotomy. Forceps 
and version find their widest application in border-line contractions of 
the pelvis and in malpositions of the head when the pelvis is ample. 
Properly symphyseotomy should not be compared with version, as its 
field of application is more limited, and a degree of contraction which 
indicates pubic section, contraindicates turning. The field of symphy- 
seotomy begins where that of forceps and version ends ; i. e., with a con- 
jugate of less than 3 J- inches. 

In flat pelves of moderate contraction version has an advantage over 
forceps, as the long occipito-mental diameter of the foetal head can be 
brought into the transverse of the inlet and the occiput guided through 
the roomiest part of the brim. On the other hand, in slight general 
contraction forceps used in conjunction with the Watcher posture offers 
the best prognosis for both mother and child. 

The comparatively recent researches of Milne Murray show that all 
of the diameters of the cranial vault are reduced by an occipitofrontal 
seizure with the forceps ; thus the supposed advantage of version, the 
overlapping and under-riding of the cranial bones, is controverted by 
practical experience. The dexterity and practice of the operator must 
also be taken into consideration in determining the relative value of 
forceps and version. The expert with the axis-traction forceps may be 
able to bring a head through the superior strait that one less skilled 
might sacrifice. However, the general rule for emergencies still holds 
good ; i. e., that where rapid delivery is demanded and the head has not 
engaged at the pelvic inlet version is the operation of choice, while for- 
ceps is to be chosen when the head is in the brim. 

Version has been successfully done in conjunction with symphyse- 

46 



722 OBSTETRIC SURGERY. 

otomy, but the liability to produce extensive lacerations of the soft 
parts does not justify its general use. Pinard's method is based on 
better surgical principles. He puts each case to the practical test of 
tentative traction with the forceps with the patient in Walcher's posi- 
tion ; if the head cannot be made to engage, pubic section is made while 
the forceps is in position. 



CHAPTER XXXIII. 



EMBRYOTOMY. 



Embryotomy is a term applied to destructive operations on the 
foetus by which the size of the head and trunk is sufficiently diminished 
to permit their passage through the birth-canal. It is a generic term 
which includes all operations designed to facilitate delivery by perfora- 
tion, crushing, or segmentation of the foetus. 

Perforation, cranioclasis, cephalotripsy, and basiotripsy are the muti- 
lating operations performed upon the head. Those on the body include 
decapitation and evisceration. 

In the present state of obstetric surgery embryotomy has but a limited 
field. As the head presents in the majority of cases, craniotomy has the 
widest range of application. 

Craniotomy. 

Indications for Craniotomy. Craniotomy is indicated in : 1. Dispro- 
portion between the size of the foetal head and the pelvis if the child is 
dead. 2. In pelvic deformity, in which the conjugata vera exceeds 2 \ 
inches, or 6.34 cm., and forceps, version, or Caesarean section is either 
impossible or dangerous to the mother. 3. In the presence of tumors 
complicating labor by narrowing the birth-canal, as malignant disease 
of the cervix and bony growths in the pelvis, when Caesarean section 
cannot be elected. 4. In prolapsed cord, when the head presents in a 
contracted pelvis with a dead child. 5. Perforation and cranioclasis 
may be done in certain cases of lateral placenta praevia in which the 
child is surely dead or non-viable. 6. In dystocia due to hydrocephalus 
not manageable by aspiration through the bregma in the forecoming head, 
or by tapping through the spinal canal when the head comes last. 7. In 
impacted posterior face presentation and in occipito-posterior cases when 
their reduction is impossible or the election of symphyseotomy would be 
unfavorable to the mother. 8. In brow presentations after the mem- 
branes have ruptured, the amniotic fluid has drained away, and a well- 
marked retraction-ring is formed. 

Is Craniotomy Ever Justifiable on the Living Child ? Stoltz and Pinard 
have declared that it is never necessary to have recourse to destructive 
measures on the living child, and some writers go so far as to say that 
" any man who, in the light of recent researches, deliberately sacrifices 
an unborn child simply confesses his ignorance of the progress of 
obstetrics." There can be no question that during the past decade 
elective Caesarean section, induction of premature labor, and the reintro- 
duction of symphyseotomy have narrowed the field of destructive opera- 
tions. But do the results of conservative operations show that the 
mother has as good a chance from Caesarean section as from craniotomy? 
It must be admitted that in hospital practice, with every facility for 
aseptic operative work, and where a diagnosis of pelvic deformity can 

( 723 ) 



724 



OBSTETRIC SURGERY. 



be accurately made before labor, elective Cesarean section has a very 
low mortality. 

In private practice craniotomy, which saves the mother, is preferable 
to symphyseotomy or Csesarean section, which gives considerable mor- 
tality. The interests of the mother must always take precedence over 
those of the unborn child. 

In country practice, where the aid and counsel of a skilled associate 
cannot be had, mutilation may be considered, after a full explanation of 
the relative merits and dangers of the life-saving operations has been 
made to the patient or her family. The author fully believes that the 
untrained physician with incompetent assistance should not elect sym- 
physeotomy or Csesarean section, as two lives instead of one are almost 
sure to be sacrificed by unskilful operation. 

Craniotomy is to be preferred to all other operations when the child 
is in danger, and the mother is ill and exhausted or threatened with 
uterine rupture. It has been suggested that the physician might delay 
operation until the child is known to be dead, and then craniotomize. 
This is dishonest and a violation of duty, for not only is the life of the 
child sacrificed, but the mother is exposed to the dangers of post-ope- 
rative shock, sepsis, and uterine rupture following upon a tedious labor. 
There is really no reason that pelvic deformity sufficient to necessitate 
embryotomy or Csesarean section should not be recognized before labor 
begins, if routine ante-partum mensuration is practised, except in cases 
seen with other physicians in consultation. If repeated and unsuccess- 
ful applications of the forceps have been made, the patient is already 
septic, and any life-saving operation will increase her risks. 

Prognosis of Embryotomy. It must be remembered that embryotomy 
in a highly contracted pelvis is not without risk to the mother because 
of the extensive lacerations of the cervix, vagina, and bladder that 
may be made in bringing a foetus piecemeal through so limited a space. 
The bruising and laceration of the soft parts lower the resistance of 
the tissues and predispose the patient to active septic infection. The 
success or failure of embryotomy depends upon the indications and the 



Fig. 423. 




Smellie's scissors. 

conditions in the particular case ; e. g., the condition of the mother at 
the time of operation, the size and the shape of the pelvis through which 
the work has to be done, and the method of extraction after perfora- 
tion has been made. The result is most favorable when that method 
of extraction is used which will do the least injury to the soft parts 
of the mother. 

In estimating the prognosis of embryotomy the following conditions 



EMBRYOTOMY. 



725 



must be taken into account : The degree of pelvic contraction, the size 
of the child, the manual skill of the operator, the physical condition 
of the patient, and the amount of bruising and laceration which she 



Fig. 424. 




Blot's perforator. 

has sustained before the operation is begun. Previous unsuccessful 
attempts at delivery with forceps and version tend to increase the 
mortality when embryotomy is performed. 

Fig. 425. 



Martin's trephine. 



Technique of Craniotomy. Mutilation of the head is accomplished by 
perforation and comminution. The perforation may be made with 
scissors, a perforator, or a trephine (Figs. 423-425). Comminution 



726 



OBSTETRIC SURGERY. 



of the cranial vault with short craniotomy forceps has given place to 
the employment of the cephalotribe and basiotribe, which are used to 
compress, crush, and extract. The cranioclast is a tractor. Decapita- 
tion is performed with the blunt hook or ecraseur. An ordinary pair 
of strong scissors and a stout, straight forceps are all that is needed for 
evisceration. 

After thorough sterilization of the operators' hands, instruments, and 
passages, the bladder and rectum having previously been emptied, the 
patient is placed on a table and anaesthetized. When the narcosis is 
complete she is brought to the edge of the table in the lithotomy posi- 
tion, and the flexed thighs held by two assistants or retained in posi- 
tion with a sheet-sling or leg-holders. 

If the head is impacted in the cavity of the pelvis, perforation 
will be easy ; on the other hand, if the head is unengaged, it must be 
firmly held against the brim by a competent assistant while the perfora- 
tion is being made. In the absence of proper assistance the skull may 
be fixed by seizing the scalp with a strong double tenaculum and the 
cranial opening made, even without anaesthesia (Fig. 426). 



Fig. 426. 




Fixing the head by seizing the scalp with a double tenaculum 



To perforate, the half hand is introduced into the vagina and the 
presentation, position, and posture reascertained. If the disproportion 
between the head and the pelvis is not too great, the head may be opened 
through a fontanelle or suture ; but if the disproportion be considerable, 
a permanent opening would better be made through one of the parietal 
bones. With the fingers in the vagina against the presenting part, to 
act as a guide, a perforator or trephine is introduced, guarded by the 
fingers, and plunged into the skull. The greatest care should be taken 



EMBRYOTOMY. 



727 



to keep the instrument at a right angle to the surface of the skull, as 
otherwise the instrument may slip between the scalp and the cranial bones 
without entering the head. If a suture is not accessible, as is commonly 
the case in flattened pelves, the hole may be made through the present- 
ing parietal bone. The point of perforation should be nearer the sym- 
physis than the promontory (Fig. 427). 

Fig. 427. 




Perforation of the after-coming head. 



The scissors are passed through the pharynx or roof of the 
mouth. 



When the perforating scissors have been passed in under steady press- 
ure to the shoulder-guard, the blades are spread apart to enlarge the 
opening ; then closed and turned at right angles to the original incision, 
when the blades are again separated. In this way a crucial incision is 
secured. When this has been done the scissors are pushed into the 
cranial cavity and moved about until the brain is thoroughly broken up ; 
special effort is made to reach and to destroy the medulla. The scissors 
are now withdrawn and the finger or fingers slipped into the opening to 
act as a guide through the remaining steps of the operation. A hard- 
rubber or metal nozzle attached to a Davidson syringe is introduced into 
the cranium alongside of the finger and the broken-up cerebral matter 
washed out. Many cases of minor dystocia will be delivered spon- 
taneously after perforation, and only where there is indication for haste, 
because of the condition of the mother, should extraction immediately 
follow perforation (Zangemeister). Having thus diminished the size of 
the head, its delivery is in order; this may be accomplished by nature 
or by traction with the finger hooked into the cranial opening, the for- 
ceps, or the cranioclast. 

It must be remembered that extraction by any of these methods is 
possible only in slight disproportion between the head and pelvis, as 
the reduction in the size of the head is accomplished by the pressure of 
the walls of the pelvis. When the skull is too hard or too large to 



728 OBSTETRIC SURGERY. 

come through in this way it must be reduced by comminution or com- 
pression. 

Perforation may be done without an anaesthetic, and done early when 
evidence of foetal death is positive, while extraction always requires 
narcosis. 

Spiegelberg advises that extraction should always follow perforation 
because : 1. The expelling powers are often inefficient. 2. Prolongation 
of the operation is always disadvantageous because of sepsis and exhaus- 
tion. 3. The opening may close by overlapping. 4. Extraction is not 
dangerous when done early. 

At what point of the foetal skull should we perforate? In vertex 
presentations, when a trephine is available, the opening should be made 
through the presenting parietal bone near the pubes. When the perfora- 
tion is made with a scissors perforator, a suture or fontanelle is selected as 

Fig. 428 




Entering the skull through the occipital bone subcutaneously. 

the site of puncture. In face presentations the perforator may be passed 
through an orbit or one of the frontal bones, or through the roof of the 
mouth behind the nasal fossa. The guiding fingers must not be withdrawn 
from the vagina until the cranioclast or basiotribe has been applied. 

After perforation of the skull its size may be reduced by comminution 
with the craniotomy forceps. The cranial bones are seized with forceps, 
which is passed beneath the scalp ; the instrument is rotated in its long 
axis until the bone is detached and can be withdrawn. The maternal 
soft parts are protected by the scalp during the torsion, and by the fin- 
gers within the vagina during the extraction of the bone. The bones are 
removed one by one until the size of the head permits its extraction. It 
may be necessary in the higher grades of pelvic contraction to crush the 
cranial base as well as the vault. The basiotribe is useful for this purpose. 



EMBRYOTOMY. 



729 



Cranioclasis. One blade of the cranioclast is introduced through the 
opening in the cranium, which has been kept patulous by the guiding 
fingers, while the other blade is applied to the external surface of the 
head. The instrument is then firmly locked and the compression screw 
in the handle turned home. With the firm grip thus secured traction 



Fig. 42 




The head after delivery by the cranioclast. 



may be made downward and backward in the axis of the pelvic brim 
until the head is brought to the pelvic floor, when the traction is con- 
tinued in an upward and forward direction, as in ordinary forceps 
delivery. Cranioclasis after careful comminution with the craniotomy 
forceps is applicable even in high degrees of pelvic contraction. 



Cephalotripsy. 

The purpose of this operation is to crush the skull in order to permit 
its passage through the birth-canal, when this cannot be accomplished by 
the cranioclast. The cephalotribe (Fig. 430) is a powerful compressing 
forceps with a strong compression screw at the end of the handle. It is 
applied to the sides of the head as is the ordinary forceps. Perforation is, 
of course, the initial step as in craniotomy. The advantage claimed for 
the cephalotribe is that it enables the operator to overcome the difficulties 
presented by a fully ossified head, in that it can be used as a crusher as 
well as a tractor. On the other hand, it has the disadvantage that, since 
it is a bulkier instrument than the cranioclast, and since both blades are 



730 



OBSTETRIC SURGERY. 



applied to the outside of the skull, it occupies more room in the pelvis, 
and that while diminishing the diameter of the head in one direction it 
increases it in another. 

This operation is applicable only in the minor degrees of pelvic con- 
traction. It is a more dangerous procedure than cranioclasis, owing to 
spicula of bone which are likely to project as a 
fig. 430. result of the forcible crushing, and also because of 

the increased room needed for its application, both 
of which causes will subject the maternal parts to 
greater traumatism. After the compression screw 
has been sufficiently tightened, keeping in mind 
that the crushed cranium is elongated in the diam- 
eter opposed to that in which the crushing force is 
applied, traction is made in the axis of the brim, 
adjusting by rotation the long diameters of the 
crushed head to the long diameters of the cavity 
and outlet. After perforation, cranioclasis, cephal- 
otripsy, or basiotripsy an antiseptic intra-uterine 
douche or one of sterile water completes the opera- 
tive technique. 

Occasionally neither cranioclasis nor cephalotripsy 
will succeed in crushing the portion of the occipital 
bone which forms the base of the cranium. If it is 
necessary to reduce the size of the base, the occip- 
ital bone must be crushed. The Tarnier basiotribe 
was devised to attain this end. This instrument is 
at once a perforator, cranioclast, and cephalotribe. 
Its chief advantage is that it may be used in a pel- 
vis of such contraction that neither cephalotribe 
nor cranioclast can be employed ; even in a pelvis 
having a true conjugate of If inches (4.44 cm.) its 
application is possible. Embryotomy through a 
brim of so high contraction should be condemned 
Lusk's cephalotribe. on general principles. Two and one-half inches 
should be accepted as the limit for successful basio- 
tripsy ; the damage to the maternal soft parts even with such a conju- 
gate will be considerable. 

The basiotribe is composed of a perforator, two blades of unequal 
length, and a powerful compression screw attached to the handles (Figs. 
431, 432). When closed and the compression screw is turned home the 
blades measure from side to side 1 j- inches, and from before backward 
If inches. Its application is as follows : the perforator is bored through 
the cranial vault and into the base of the skull ; when this is driven 
home the blades are applied to each side of the skull, locked, and the 
compression screw tightened until the base is thoroughly crushed. 
Extraction is then completed as when the cranioclast or cephalotribe is 
used. 

Decapitation. 

Decapitation, or the removal of the head from the body, is an opera- 
tion which is fortunately rare in modern midwifery, because of a more 




EMBRYOTOMY. 



731 



accurate diagnosis and earlier interference on the part of the physician 
than formerly in transverse presentations of the foetus. 

The indication for performing such mutilation is a neglected trans- 
Terse presentation which has become impacted, foetus dead, and a retrac- 
tion-ring so well defined that rupture of the uterus is imminent and 
version positively contraindicated. 

Foetal monstrosity may render delivery impossible except by decapi- 
tation or evisceration. In transverse cases which justify such procedures 
the position of the neck will determine which is the more feasible. Where 



Fig. 431. 



Fig. 432. 





Tarnier's basiotribe. 



Basiotripsy accomplished. 



the neck is accessible and a hook can be passed over it, decapitation is 
the operation of choice ; on the other hand, when the neck of the foetus 
cannot be reached evisceration is the operation of election. 

Braun's decapitating hook, or decollator, is the most efficient instru- 
ment yet devised to divide the vertebral column. This consists of a 
steel rod fitted with a strong transverse handle at one end and a short 
blunt hook at the other. The hook forms an acute angle with the shaft 
of the instrument (Fig. 433). The hook is passed over the neck of the 
child and pulled down until the neck rides well up into the apex of the 



732 



OBSTETRIC SURGERY. 



angle. Then by a steady pendulum motion, accompanied with traction 
on the handle, the neck is severed. 

A strong cord or a chain-saw may be utilized to behead the foetus 
when a decapitating hook is not at hand, if the neck is sufficiently 
accessible to permit of its passage above it, or the passage of a well- 
lubricated elastic catheter, to which the cord or saw may be attached and 
carried into place. This procedure is always attended with consider- 
able difficulty, owing to the skill and patience which are required to 
pass either catheter, cord, or saw about the neck. A knot or a loop at 
the end of the cord facilitates the manipulation. When the cord has 



Fig. 433. 



Fig. 434. 



A 





Carl Braun's decapitation hook. 



Decapitation by the hook. 



been put in place the two ends are to be brought out of the vagina and 
a tubular speculum passed over the ends and into the vaginal orifice, to 
protect the tissues while the neck is sawn through. 

To insure the safety of the mother during decapitation a most scrup- 
ulous aseptic technique is imperative. Since these patients are often 
already septic and lacerated to a greater or less degree, further infection 
and traumatism to the maternal soft parts must be carefully guarded 
against. After the bladder has been emptied the hands of the operator, 
instruments, and the field of operation are rendered aseptic and the 
patient anaesthetized and placed in the lithotomy position. A foetal 
arm, if accessible, is brought out of the vagina and given to an assistant 



EMBRYOTOMY. 733 

to make traction on, in a downward and backward direction. This 
steadies the neck and brings it within reach. A noose of tape looped 
about this arm facilitates the subsequent manipulations, by permitting 
downward and backward traction to be made on it, without the assistant 
being in the way of the operator. The operator inserts his half or 
whole hand into the vagina. The right hand is chosen if the head is 
to the mother's left, and the left when the head is to the mother's right. 
Two fingers are now passed along the pubic or sacral wall of the pelvis 
and into the uterus until they can hook over the neck. If the dorsum 
is to the mother's front, the fingers may be passed along the pubic side ; 
if to the mother's back, advantage will be gained by carrying the hand 
along the sacrum. 

The hook is now run in flat, along the fingers, and guided around the 
neck from above downward. When in place firm traction is made 
upon it, while the hook is rocked back and forth until the neck yields. 
The fingers must be kept in position to guard the maternal structures 
from injury. 

After the head is severed from the trunk the body may be delivered 
by traction on the prolapsed arm and the head slips upward as the 
trunk glides by. The head may be extracted by seizing the inferior 
maxilla with the fingers to maintain flexion and control rotation while 
suprapubic pressure is made with the other hand, or by forceps if the 
pelvis be sufficiently ample to permit cephalic engagement. If, on the 
other hand, the pelvis is so contracted as to make engagement by the 
suboccipito-mental, suboccipito-frontal, and bitemporal diameters impos- 
sible, the head may be steadied against the brim, perforated, and ex- 
tracted by cranioclasty or basiotripsy. 

Decollation in Locked Twins. Decapitation may be necessary to relieve 
the impaction in case of twin presentation with locked chins. The child 
partly born with the breech presenting is usually dead ; if it is not, the 
chance of life is so small that it may be sacrificed in the interest of the 
other twin. A strong, blunt-pointed curved scissors may be utilized to 
sever the neck in this location ; to prevent the scissors from slipping up 
and doing damage to the maternal structures, a piece of stout rubber 
tubing may be tied about the neck, and the vertebral section made below 
this guard. 

Evisceration and reduction in the size of the trunk are elected in cer- 
tain cases of transverse presentation of the foetus, in which the neck is 
inaccessible to the hook, in breech births where the foetus is too large to 
pass through the pelvis, or when because of monstrosity or pathological 
enlargement of the foetal structures delivery without mutilation is im- 
possible. 

The abdomen or the thorax maybe opened with blunt-pointed scissors 
and the viscera removed with the fingers or forceps. The ribs are 
divided to diminish the size of the chest, and the clavicles severed 
(cleidotomy) in their middle third to reduce the transverse measure- 
ment of the shoulders. Extraction is made with the blunt hook or 
cranioclast. 

When the back of the foetus presents, making decapitation and evis- 
ceration as ordinarily performed impossible, the trunk may be steadied 
with a strong volsellum forceps and the spinal column divided with 



734 OBSTETRIC SURGERY. 

scissors ; with the trunk thus opened from the back, it may be seized 
and drawn down by the cranioclast until the body can be snipped through 
with scissors. The two halves may now readily be reduced and delivered. 
Should the arms embarrass extraction, they may be amputated. 

During decapitation and evisceration the mother is subjected to the 
danger of sepsis and laceration of the soft parts. The first is guarded 
against by strict attention to aseptic detail, and an antiseptic intra-uterine 
douche should follow delivery, when necessary for the removal of loose 
shreds of tissue which otherwise might be retained. Immediate suture 
should be made of all accessible maternal lacerations. 

Arrest of the after-coming head at the brim or within the cavity of 
the pelvis may demand craniotomy ; under such circumstances the child 
is usually dead and the indication is clear. Of the various procedures 
recommended for these cases, the method described by Strassmann is 
especially safe, thorough, and practical : " The head is fixed by intro- 
ducing the index and middle fingers into the open mouth and making 
traction upon the lower jaw. The breech of the child is carried up over 
the pubes toward the mother's abdomen, and a scissors perforator is 
then passed through the pharynx to the base of the skull, and through 
the foramen magnum, dividing the bones between the occipital condyles." 
A metal catheter is introduced through this opening and the brain care- 
fully broken up and washed out. 

To complete the delivery the head is flexed by making traction on 
the lower jaw with the index and middle fingers, which are introduced 
into the mouth, while suprapubic pressure is applied with the other 
hand. Should manual extraction fail, labor may be terminated by the 
forceps or cranioclast. Perforation through the mouth is usually safe. 

Hydrocephalus of an after-coming head, causing dystocia, may neces- 
sitate craniotomy, since the position of the head is so high in the pelvis 
that the mouth is not readily reached. Successful perforation may be 
made through a skin incision at the base of the neck posteriorly ; the 
perforator being passed under the skin, is made to enter the occipital 
bone, and extraction is accomplished by the cranioclast. 

In minor degrees of hydrocephalus puncture of the spinal canal to 
allow for the escape of cerebrospinal fluid may reduce the cranial 
diameters sufficiently to permit their passage through the pelvis. This 
procedure and aspiration through a fontanelle in the forecoming head 
do not necessarily cause the death of the child. 

Craniotomy in connection with symphyseotomy has been suggested and 
been performed as an emergency procedure ; but such an operative com- 
bination cannot be considered as advisable in the light of modern 
obstetrics. 

Embryotomy is generally inadmissible in pelves below 2-|- (6.34 cm.) 
inches, while 2|- (6.97 cm.) inches is the lower limit for symphyseotomy. 
Basiotripsy followed by evisceration would do less damage to the mater- 
nal structures than the above-mentioned combination. The occasion for 
embryotomy with pubic section could arise only from poor judgment or 
from a failure to recognize pelvic contraction by previous examination 
during pregnancy or at the time of labor. So high a degree of contraction 
as to necessitate these operations should be apparent to the most casual 
observer. Again, many of these patients are already septic from re- 



EMBRYOTOMY. , 735 

peated examinations and ineffectual attempts with forceps and version 
before symphyseotomy is considered, which fact of itself would contra- 
indicate pubic section. 

Prognosis for Embryotomy. In skilful hands and in properly selected 
cases embryotomy is a comparatively safe operation. The time at which 
the operation is done, the size of the pelvis, and the condition of the 
maternal soft parts influence the prognosis. The maternal mortality 
and morbidity from embryotomy are higher in private than in hospital 
practice. This is accounted for by the lack of accurate estimation of 
the relative size of the foetus and pelvis, which is unfortunately too 
common in private work, and by the fact that embryotomy is made as 
an operation of last resort, after ineffectual attempts at delivery with 
forceps, in an exhausted, septic, and lacerated woman. 

Choice of Procedure. The higher degrees of contraction which call for 
basiotripsy and evisceration increase not only the mortality, but also the 
morbidity to the mother ; and if the womb is already septic and the 
woman's strength is good, Caesaro-hysterectomy may be elected, with the 
possibility of improving the prognosis. 

In rupture of the uterus, if the rent is incomplete and the foetus has 
not escaped into the abdominal cavity, craniotomy may properly be 
elected. After the child has been extracted the tear may be tamponed 
with iodoform gauze. Where the child or the greater part of the ovum 
has escaped from the uterus, making the foetal parts accessible, embry- 
otomy must give place to abdominal section. 

In concluding, the author believes that the choice should be between 
Cesarean section and embryotomy in high degrees of pelvic contraction ; 
and as accurate and early diagnosis and pelvimetry become more common 
the field of mutilation will become more limited. 



CHAPTER XXXIV. 

CESAREAN SECTION. PORRO OPERATION. SYMPHYSIOTOMY. 

CESAREAN SECTION. 

Cesarean section is an operation for the delivery of the child at term 
by means of an incision through the abdominal and uterine walls. 

It is commonly assumed that Csesarean section takes its name from 
Csesar, who is said to have come into the world in this way. Pliny, 
however, derives the term from the Latin ccedere, " to cut," and men- 
tions several other celebrities of ancient times, among them Scipio 
Africanus and Manlius, as being among the number of " Ccesones" as 
they were called. 

The practice of Cesarean section belongs to prehistoric times. A 
Roman law, ascribed to Numa Pompilius, forbade the burial of a preg- 
nant woman before the foetus had been taken away from her, and this 
was generally done through an abdominal incision. 

It having been once shown that many children were saved in this 
way after the death of the mother, the question arose whether it would 
not often be right in cases of protracted labor, and where the life of the 
child, although not that of the mother, was threatened, to perform 
Csesarean section. The proposal, however, met with bitter opposition. 
It was urged that to open the abdomen of the mother, even when her 
condition is hopeless, in order to save the child, is a criminal procedure, 
and Virchow cites an instance in which a physician was prosecuted for 
performing Csesarean section on a dying woman, with the hope of saving 
the child. 

The first recorded Caesarean section on the living woman was per- 
formed in the year 1500 in Switzerland, by one Jacob Nufer, a butcher, 
who is said to have saved the life of his wife in this w r ay. It is further 
stated that he operated many times. The procedure subsequently passed 
from the hands of the butchers into those of the barbers. 

In Germany, Trautman was the first to deliver a child through an 
incision in the uterine wall. He operated in 1610, in a case of hernia 
of the gravid uterus. In 1881 Rousset published a treatise in French 
on this subject, and cited nine cases, to which six w r ere added by Casper 
Bauhin in his Latin translation of Rousset's work. Many authors have 
since tried to prove that these were not cases of genuine Csesarean sec- 
tion, but were simple laparotomies for ectopic pregnancies. It is diffi- 
cult to believe that operation for extra-uterine pregnancy could have 
been so common in those days. 

A great deal of discussion has been directed to the treatment of 
the uterine wound. In former times the uterine wound was left un- 
sutured. Sanger has done great service by the introduction of a secure 
uterine suture. 

Porro recommended that the older operation should be supplemented 
by the removal of the uterus. 

(736) 



CESAREAN SECTION. 737 

Indications. The indication for Csesarean section may be (1) absolute 
and (2) relative. 

Cesarean section on the living woman should be undertaken in cases 
in which there is no prospect that the foetus, even after embryotomy, can 
be extracted by the natural passages with less danger to the mother. In 
pelves measuring 6.5 cm., about 2J inches, in the conjugate diameter with 
a living child, or 5 cm., 2 inches, with a dead child, Csesarean section is 
necessary to save the mother's life. Here the indication is absolute, be- 
cause no other less dangerous alternative presents itself. It is said to 
be relative when the operation is elected in preference to other possible 
methods of delivery. 

Even in pelves with a conjugate diameter of 6.5 to 7 cm., elective 
Csesarean section is a better operation than its alternatives. Its mortality 
in elective operations should not exceed 5 per cent, for the mothers and 
the same for the children. While the maternal mortality of induced 
labor is practically nil, the infant death-rate from prematurity is about 33 
per cent. The best results of symphysiotomy are about the same as 
those of Csesarean section for the mothers, but the infant mortality is 
greater ; but the best results are not possible in pelves below 7 cm. 
Embryotomy is not entirely without maternal death-rate, and the children 
are all sacrificed. 

With a conjugate diameter of more than 7 cm. choice must be made 
between Csesarean section, induced labor, symphysiotomy, and crani- 
otomy. The prognosis for induced labor in slight contraction is better 
than in the class of pelves last considered, since the viability of the child 
is greater. When the time for induced labor has passed the choice of 
operation lies between Cesarean section and symphysiotomy. When the 
mother is exhausted by long labor and repeated attempts at delivery or is 
otherwise in bad condition for abdominal section, symphysiotomy offers 
the best prospect. It may be elected in advance of labor as an alterna- 
tive of Csesarean section in very moderate degrees of contraction. When 
the child is dead or non-viable or a monster, craniotomy should be per- 
formed in the interest of the mother. In all other conditions and at the 
hands of an operator trained in abdominal surgery the Csesarean opera- 
tion may be performed. 

We believe with Williams, of Baltimore, that the upper limit for the 
absolute indication for Csesarean section should be advanced to 7 cm., 
and the relative indication to 8.5 cm. for flat, and 9 cm. for generally 
contracted pelves. Williams holds that Csesarean section should be per- 
formed in preference to symphysiotomy in minor degrees of contraction, 
in w T hich forceps or version is inadequate. He would, therefore, when 
the relative indication is present, allow the labor to go on for one hour in 
the second stage, and would then elect Csesarean section in preference to 
high forceps on the movable head, or to version if the head fails to sink 
into the pelvis after moulding. 

An examination should always be insisted upon before the eighth 
month of pregnancy, to decide whether narrowing of the pelvis exists. 
If the measurements of the pelvis are determined in good time, we shall 
be able to select our method of procedure, and thus be better prepared to 
meet any emergency. 

The time at which the operation should be performed is just before 

47 



738 OBSTETRIC SURGERY. 

the end of pregnancy. By the history and symptoms, and by accurate 
measurements combined with palpation, it is possible to decide approxi- 
mately when the foetus is mature. It is not necessary to wait until labor- 
pains come on to ensure contraction of the uterus after delivery ; neither 
is it necessary to wait for marked dilatation of the cervix to insure 
drainage from the uterine cavity afterward. Sometimes, for obvious 
reasons, the surgeon may be compelled to operate during labor. 

Preparation. In addition to the usual dressings and accessories the 
instruments needed for the operation are : 

1. Scalpels ; 

2. One dozen artery-forceps ; 

3. One pair of scissors ; 

4. A large thin-walled rubber tube as a uterine ligature ; 

5. Needles threaded, with carriers ; 

6. Needle-holder. 

A careful chemical and microscopical examination of the urine should 
have been made previously on more than one occasion. The patient 
should have been kept, if possible, under observation for some time. 
The bowels should have been carefully regulated. 

On the evening preceding the operation the abdomen should be pre- 
pared aseptically as for an ordinary coeliotomy. The abdomen and pubes 
are shaved, and a compress of bichloride (1 : 1000) is applied and kept 
on until the patient is brought to the operating-table. 

The Operation. After being anaesthetized, the patient should be 
placed on the table with the buttocks resting upon the perineal pad. 
The healthy vagina in the gravid woman needs no disinfection. If 
diseased it should be cleansed thoroughly by scrubbing with soft soap on 
a ball of absorbent cotton held in stout forceps, every fold being 
exposed. It may afterward be irrigated with a 10 per cent, solution of 
creolin. About a drachm of iodoform and boric acid powder (1 : 7) may 
then be thrown up into the vault of the vagina, the cavity being after- 
ward filled with a pack of iodoform gauze. In health all interference 
within the vagina should be omitted. The toilet of the abdomen is com- 
pleted in the usual manner. 

The operator may by external examination obtain a clear idea of the 
position of the child in the uterus. Just before the final cleansing of the 
abdomen the strength and frequency of the foetal pulse should be noted. 

The upper abdomen, the chest, the thighs, and the flanks are covered 
with sterilized towels; a large piece of gauze of four thicknesses covers 
the whole body from the chest to the knees, a slit being cut in it from 
the navel to the symphysis. If the head is wedged in the pelvis, the 
towels and gauze which cover the upper part of the thighs should be so 
arranged that an assistant may exercise upward pressure with the hand 
through the vagina during the extraction of the child. 

The operation is often done in from twenty to twenty-five minutes ; 
sometimes it takes three-quarters of an hour. 

The length of the abdominal incision must be greater ^yhen the uterus 
is to be brought out of the wound before opening it, than when it is 
incised in situ. With the former method the uterus can be kept under 
better control, and it is easier to prevent the entrance of fluids into 
the abdominal cavity. But against this must be put the great length 



CESAREAN SECTION. 739 

of the incision, which presents the following disadvantages: (1) an 
extensive scar, with consequent weakening of the abdominal walls, often 
followed by hernia ; (2) the greater extent of adhesions occurring later 
between the uterus and the abdominal wall, which are likely to be in 
proportion to the size of the cicatrix. Upon this point Zweifel lays great 
stress. With the second method an incision of 15 cm., 6 inches, will 
usually be sufficient, and this shorter incision is generally to be preferred. 
The description which follows will deal, therefore, more especially with 
a Cesarean section in which the uterus is incised and evacuated in situ. 
The rubber ligature is now adjusted by passing its loop over the fundus 
and tying it lightly by a single knot around the isthmus. 

The uterus is incised from the fundus to a point just short of the 
retraction-ring. The incision is carried boldly through the whole thick- 
ness of the uterine wall, notwithstanding the bleeding, which may be 
quite free. The incision extends from a point about 1\ cm., 1 inch, 
below the umbilicus to within a similar distance from the symphysis. The 
abdomen is opened by first cutting through the skin and fascia and sepa- 
rating the muscles by blunt dissection. An assistant, with a pair of 
forceps, now catches and raises a small portion of the peritoneum, and 
the operator, with a second pair, takes hold of another portion at a point 
a short distance from the first pair. A nick is then made between the 
two forceps, and the operator, having introduced the finger into the 
opening and using it as a guide, cuts through the remainder of the peri- 
toneum. The uterus is now brought into view, and an elastic ligature is 
passed over the fundus and placed around the lower segment. The two 
ends are held by an assistant, who exercises traction, compressing the 
uterus and fixing it against the symphysis. The latter procedure serves 
two purposes ; it keeps the uterus steady and at the same time prevents 
excessive hemorrhage. 

The location of the placenta may usually be determined before incision 
of the uterus. When the round ligaments are far apart converging down- 
ward the placenta is upon the anterior wall. When the reverse is the 
case the placental insertion is upon the posterior wall. It was formerly 
taught that the incision through the uterine wall should always be made 
to one side of this area, but with our present methods this precaution is 
unnecessary. 

If the placenta lies in the way, it is the usual practice to detach 
the edge and push it to one side. Time is saved and no more bleed- 
ing is occasioned by cutting rapidly through it. When the placenta does 
not underlie the incision, the membranes will be seen pouting through the 
incision and presenting a blackish appearance. 

The assistant now presses the abdominal wall toward the sides of the 
uterus, and the operator, passing his hand through the membranes into 
the uterine cavity near the fundus, grasps the nearest fcetal extremity 
and, drawing it out, rapidly extracts the child. 

A leg mav be seized if it can readily be found, or the child may be 
delivered bv the buttock. As a rule, the extraction of the child is easily 
and speedily effected by grasping the head with both hands. Usually 
the uterus now contracts, and bleeding is in the main controlled. 

Fritsch recommends a transverse uterine incision at the fundus. 
Jewett has operated by this method, in two cases. Midler opens the 



740 OBSTETRIC SURGERY. 

uterus at the fundus, but longitudinally instead of transversely. The 
chief advantage of the fundal incision is greater security in closing the 
wound. It insures the avoidance of the lower non-contractile portion 
of the uterus, in which it is difficult to close the wound securely. The 
median longitudinal incision between the fundus and the ring of Bandl 
is almost universally preferred. 

While an assistant holds the child in a large piece of sterilized gauze, 
the operator applies two clamps to the umbilical cord and cuts between 
them. The child is then handed over to an assistant and the stump of 
the cord is ligated at leisure. 

When this has been done, the hand, inserted into the uterus, grasps 
the foetal surface of the placenta. The fingers are then closed upon it, 
squeezing it like a sponge. In this way it is freed from its uterine 
attachment and gradually withdrawn, the membranes peeling off from 
the uterine wall. 

The uterine wall has thus far been protected by the amniotic mem- 
branes from risk of infection. If left untouched, it remains aseptic. No 
douching and no dusting with antiseptic powders is required. As a rule, 
the hemorrhage will be slight ; but should it be excessive the flow may 
be controlled temporarily by an assistant, who should grasp the uterus 
below the body or tighten the ligature around the lower segment. 

The objection to tightening the rubber ligature primarily lies in the 
fact that tight and prolonged constriction may paralyze the nerves and 
favor uterine relaxation and subsequent hemorrhage. The uterus should 
be stimulated to contract by friction and by the application of hot towels, 
and, if need be, by faradism. The same object is promoted by the sub- 
cutaneous injection of a half drachm of fluid extract of ergot immedi- 
ately before the abdominal incision. Oozing may be checked by the 
application of cheese-cloth sponges wrung out of hot water. 

The contracted uterus may now be lifted out of the abdominal cavity 
and laid upon a large piece of sterilized gauze, which also serves to 
prevent protrusion of intestines. Or the uterus may better be sutured 
in situ , without removal from the abdomen. 

The uterine incision is closed w T ith a row of deep or catgut interrupted 
sutures, half-deep sutures being inserted between for accurate approxima- 
tion. Finally, a row of superficial sutures is so placed as to cover in the 
deep layers. (Fig. 435.) The first sutures should be laid at intervals of 
about 1.5 cm. apart, being introduced on the peritoneal surface of the 
uterus about half a centimeter from the edge and brought out on the 
wound surface just where the decidua and muscularis come together. 
The line of separation is easily recognized. They are then entered on 
the opposite surface of the wound at corresponding points and brought 
out on the peritoneal surface of the uterus on a line with their points of 
entrance. If hemorrhage is still going on, these sutures should be tied 
as soon as possible after their introduction, until the bleeding points are 
reached and the flow is controlled. 

Each suture is tied firmly enough to bring the surfaces snugly to- 
gether and stop hemorrhage from the wound as well as from the suture- 
punctures. Slight blanching of the surrounding tissues at the point of 
entrance and exit will show when the sutures are tight enough. If they 
are too tense, the circulation will be completely cut off from the wound and 



.CESAREAN SECTION. 



741 



the risk of septic infection will be rendered greater by the decreased resist- 
ance thus produced. The half-deep or superficial sutures are next inserted. 
The deep sutures are completely covered in and concealed by the 
introduction of a layer of superficial sutures along the whole length of 



Fig. 435. 




Diagrams to show the placing of sutures in the uterine wound after Csesarean section. (Sanger.) 
p. Peritoneum, f. Uterine fibre, m. Mucous or decidual layer, u. Deep uterine sutures, s. Super- 
ficial serous suture. 



the wound. Each of these is made to enter and emerge on the peri- 
toneal surface just outside the line of the deep sutures, and should 
include just enough tissue to secure a firm hold. The suture is then 
carried across the incision and through a fold of peritoneum on the op- 
posite side. The peritoneum is thus drawn over the deep sutures, form- 
ing a welt which covers the wound in the uterus. This method of 
suturing the serosa is analogous to the intestinal sutures devised by 
Czerny and Lembert. 

The row of superficial sutures provides against the invasion of the 
peritoneal tract better than any other method, and is especially useful 
where the labor has been prolonged and forceps or other manipulations 
have been employed, whereby the patient has become much exhausted. 
After all the sutures have been introduced, if everything has gone right, 
the wound surface should remain dry. 

Instead of the foregoing method Palmer Dudley uses running catgut 
sutures in two or three tiers. 

The uterus being now drawn forward, the gauze covering the intes- 
tines is removed and the peritoneal surfaces are cleansed of blood and 
liquor amnii by gently pressing them with a dry cheese-cloth sponge. 

Particular attention should be paid the renal fossa?, a fresh, clean 



742 OBSTETRIC SURGERY. 

sponge on a holder being carefully carried up into each. The surface 
of the intestines and of the pelvic cavity behind and in front of the 
uterus and broad ligaments should also be sponged clean. The uterus, 
if it has been lifted out, is now replaced within the abdomen, with its 
anterior surface facing the abdominal wall. 

For future reference it is well to make a direct internal measurement 
of the conjugata vera, using for the purpose a sterilized sound. 

The omentum should be brought down in front of the uterus. 

After the uterus has been replaced the abdominal wound is closed by 
means of a continuous fine catgut suture for the peritoneum, interrupted 
silk-worm gut sutures being employed to bring together the fascia and 
overlying structures and, if needed, subcuticular sutures also for the skin. 

The occlusive abdominal dressing is applied and held in place by a 
suitable bandage. 

The vulvar orifice having been relieved of its pad, the urine is drawn, 
after which the vulva is covered with a loose pad of absorbent cotton ; 
this is changed every three or six hours. 

After-treatment. The after-care of the patient is very important. 
It may be necessary to give one or two hypodermic injections of mor- 
phine, J— \ gr., to insure the patient a good rest on the first night. After 
the first twenty-four hours there will be but little pain, and the hypo- 
dermic injections under ordinary circumstances must not be continued. 
The child should be put to the breast after twenty-four hours, and subse- 
quently at regular intervals of two hours during the day, and once or not 
at all at night. 

The bowels of the patient should be opened on the third day. 

As soon as she is able, she may be allowed to pass her water, and 
after each act of urination the parts should be cleansed by irrigating 
with boric acid solution. 

The subcuticular suture if non-absorbable may be removed about the 
tenth day and the silk-worm after fourteen days. After two weeks the 
patient may be lifted out of bed and allowed to remain for a short time 
each day in a reclining-chair. During the third week she may sit up 
for a part of the day, and during the fourth week may begin to walk. 
An abdominal bandage may be worn for several weeks or months. 

It is important to determine the position and size of the uterus two or 
three months after the operation, and to ascertain whether fixation to the 
abdominal wall exists. 

In addition to the foregoing, the following points in the technique of 
the operation are worthy of mention : 

1. In private practice the operation is most frequently performed at 
the patient's home, and since to-day we ought to preserve almost equally 
well our aseptic technique in a private house as in a hospital, care 
should be taken that all necessary preparations are made beforehand, 
and not left till the operation has begun. In this way the different 
steps may follow one another with the utmost rapidity consistent with 
accuracy and attention to detail. 

2. If the uterus has probably been infected before operation, the 
conservative Csesarean section is not sufficient, and the whole organ 
must be removed. 

3. Drainage must be provided by way of the vagina. 



THE PORRO OPERATION. 743 

THE PORRO OPERATION. 

Porro preferred to supplement the ordinary Cesarean section by am- 
putating the uterus in its lower segment, the tubes and ovaries being 
also removed. The advantages claimed for this operation, which is more 
mutilating than the one just described, are as follows : 

1. There is no risk of hemorrhage from the uterine incision either 
during or after the operation ; 

2. The woman will never again be put in the same dangerous situation. 
Indications. 

The Porro-Csesarean. section is indicated, therefore : 

(1) "When the labor has been prolonged, the membranes have been 
ruptured for some time, and manipulations have been undertaken involv- 
ing the uterus which make the occurrence of sepsis very probable. 

(2) In the presence of active gonorrhoeal infection. 

(3) "When the uterus or appendages are diseased to such an extent that 
a subsequent operation will certainly be necessary for their removal. 

(4) In pelvic contraction or obstruction in the soft parts, rendering 
the delivery of a subsequent child impossible, it is justifiable, with the 
consent of the patient and her relatives, to prevent by Porro's operation 
the recurrence of pregnancy, which has already proved so dangerous. 
Failure of uterine contractions after Csesarean section may necessitate 
hysterectomy. 

The technique of the operation is, in the first steps, the same as in the 
one just described. After the extraction of the child the uterus is 
eventrated, and the ligature around the lower segment of the uterus is 
tied tightly -to control the circulation. The uterus is cut rapidly away 
at a point 2^- or 3 cm. above the ligature, and the tubes and ovaries are 
also removed. The operation is completed by ligating the ovarian ves- 
sels and each of the uterine vessels in the stump. The part of the 
uterine cavity above the rubber ligature is disinfected with pure carbolic 
acid, applied by means of absorbent cotton on an applicator. 

In the original Porro operation the abdominal wound is closed down 
to the stump, the peritoneum around the lower angle of the wound 
being attached by a running suture on all sides to the pedicle, thus com- 
pletely shutting off the peritoneal cavity. 

The stump is kept from retracting into the abdominal cavity and 
slipping out of the knot by forcing two sterilized knitting-needles 
through the rubber ligature and the stump. These needles rest upon 
pads which protect the surface of the abdomen. 

This method of procedure has been superseded by the subperitoneal 
method of hysterectomy as commonly practised in supravaginal amputa- 
tion of the non-gravid uterus. For a detailed account of the procedure, 
text-books on gynecology may be consulted. 

Vesical disturbances do not arise generally in these cases, there being 
abundant room in which the bladder can expand. 

SYMPHYSIOTOMY. 

Symphysiotomy (from a'jfupoatc^ a joint, and ro/ifj, a cutting) is an 
operation for the artificial division of the pubic symphysis in woman 



744 OBSTETRIC SURGERY. 

in labor, in order to increase the diameters of a narrowed pelvis, and 
thus to permit the birth of a living child through the genital canal. 

History. The operation was performed on a dead woman, in place of 
a post-mortem Csesarean section, for the purpose of saving a living 
child, by Jean Claude de la Courvee, at Warsaw. The date is var- 
iously given as 1644 and 1585. A similar operation was performed by 
Joseph Plenck in 1776. That a separation of the pelvic bones exists 
during the later months of pregnancy was recognized even in the early 
days of medicine, and allusions to it can be found in the works of 
Hippocrates and Avicenna. Galen held that the pubic symphysis was 
a true joint, while Yesalius taught that the pelvic bones were united 
by cartilage. In 1519 Jacques Amboise conducted a careful autopsy 
on the body of a woman who had been executed a few T days after labor, 
for child-murder, and demonstrated that a separation of the pelvic bones 
existed, with no sign to show that it was other than a normal physio- 
logical condition. Severin Pineaud, who assisted at the examination, 
deemed the findings of such importance that he incorporated them in a 
brochure, which, however, was not published till 1775. The symphysis 
was found to be markedly affected, the synchondrosis being much soft- 
ened, owing to an apparently physiological succulence of the tissues, 
which was ascribed to pregnancy. 

It was, no doubt, the knowledge that a certain degree of separation or 
relaxation of the pelvic joints exists normally during pregnancy, which 
suggested the possible advantage of the operation upon the living woman. 
Such a procedure is certainly an attempt at a close following of Nature's 
own method of preparing the pelvis for the passage of the child, and 
goes only a step farther in that it makes disruption of a joint where 
nature has provided only a relaxation. 

Although the credit of proposing the operation on the living woman, 
with the intention of delivering a viable child, belongs to Rene Sigault, 
who, while yet a student in Paris, advocated the procedure in 1768 
before the French Academy, an Italian surgeon, Domenico Ferrara, 
who had been in Paris, and who was acquainted with Sigault' s views, 
was first to carry out the suggestion. Ferrara operated in Naples, in 
1774. The woman died. Sigault himself performed his first symphysi- 
otomy in 1777, at Paris. The patient was a soldier's wife, who had 
previously given birth to four children, all born dead. The conjugate 
was said to have been about 6.5 cm, 2} inches. The operation was 
successful, and the woman had so far recovered in two months that she 
was able to leave her house and was presented for examination by Sigault 
at a meeting of the Faculty of Medicine. The Academy of Surgeons, 
with Baudelocque at its head, bitterly opposed the new operation. 
Their position was strengthened by the facts that Sigault's patient was 
left with a vesico- vaginal fistula, and that she also suffered from pro- 
lapse of the vaginal walls and of the uterus, and had an unsteady, wad- 
dling gait. In spite of this relatively ill success and the condemnation 
of the procedure in high places, Sigault was hailed by many as a public 
benefactor, and several similar operations were performed. Although 
the results by themselves would go to show that the hostility of the 
French surgeons was not without some show of reason, it must be re- 
membered that : (1) the limits of the operation had not been worked out ; 



SYMPHYSIOTOMY. 745 

( 2 | methods of pelvimetry were crude and imperfect, and it could not 
be otherwise than that the operation would be applied in unsuitable cases; 
(3) cases, many of them ill chosen, were operated upon under different 
circumstances by various surgeons, some of w r hom did not possess the 
requisite skill. In the light of modern discoveries it is to these factors 
that in a great measure must be ascribed the high rate of mortality in 
the mothers, which was even exceeded by the fatalities in the case of the 
children. Sigault himself operated 6 times, and lost 1 mother and 5 
children. De Cambon operated 4 times, and lost 1 mother and 2 chil- 
dren. Leroy operated 4 times, and lost 1 mother and 1 child. 

Harris' statistics show that in 105 symphysiotomies performed be- 
tween 1777 and 1866 the maternal mortality was 31 per cent., while 15 
per cent, of the children died. Neugebauer records 136 cases between 
1776 and 1866, 56 of which were performed in Italy. Of these 56 
cases, 22 mothers recovered, and 18 died; in 16 the results are not 
recorded. Of the children, 16 were born alive, 22 died ; in 16 the re- 
sults are uncertain. Between 1815 and 1841 Galbiati operated 18 
times. From about 1820 to 1890 the operation was almost entirely 
confined to Naples. Harris states there were no reported cases between 
1858 and 1865, when Bellozi, of Bologna, operated, but lost the mother. 
Morisani, of Naples, in 1866, working in the same hospital in which 
Ferrara had performed his first symphysiotomy, carried out the pro- 
cedure successfully ; mother and child both survived. From this time 
the operation began to be more generally employed, though up to 1890 
the majority of all symphysiotomies had been done at Naples by Moris- 
ani and his pupils. Harris, writing in 1883, says that in the seventeen 
years preceding more symphysiotomies were performed in Italy than in 
the rest of the countries of the world put together. In 1881 Morisani 
published 50 cases, with 80 per cent, of successes, 41 mothers and 41 
children surviving. In 1885 the same authority published 18 addi- 
tional cases : 10 mothers and 13 children living. 

In 1891 Spinelli, a pupil of Morisani, went to Paris to lay the results 
obtained at Naples before the French profession. Between 1888 and 
1891 he collected 24 cases, out of which 24 mothers and 23 children 
were saved. His results and those of Morisani made a favorable im- 
pression upon Pinard, who became an earnest advocate of the operation, 
and performed 19 symphysiotomies in something over a year, saving 19 
women and 16 children. 

The first reported case in America was performed by Jewett, who 
operated on September 30, 1892. Barton Hirst, of Philadelphia, did the 
operation a few days after Jewett. 

Symphysiotomy was introduced, in the main, as an alternative for 
Csesarean section. The maternal mortality in the latter, as originally 
practised for over eighty years, had been approximately 100 per cent., 
and it can hardly be wondered that any procedure which promised 
better results should be hailed as a godsend. The history of all new 
operations w T as repeated. Cases Avere subjected to symphysiotomy where 
the conjugata vera was so small, or where the pelvis was so deformed, 
that, as Baudelocque demonstrated, it w T as impossible to make the head 
engage after division of the symphysis. Such cases were manifestly out 
of the province of symphysiotomy. Again, the technique of the opera- 



746 OBSTETRIC SURGERY. 

tion was faulty. The bladder and urethra were often injured. The 
peritoneal cavity was in many instances laid open, and sepsis was a fre- 
quent result in these early operations. In some of the fatal cases, even 
where the conjugata vera did not measure under 2-J- inches, 6.5 cm., the 
sacro-iliac joints were found ruptured and filled with pus. 

Present Status of the Operation. Since the advent of antiseptic sur- 
gery the statistics of the operation have greatly improved. In 210 cases 
operated on since 1886, 1 12.85 per cent, of mothers and 20.2 per cent, 
of children died. These operations were performed by all sorts of 
surgeons, possessing varying degrees of skill, dexterity, and surgical 
judgment. If the results of the best operators be taken by themselves, 
the mortality will be found to be much less. Morisani, for example, in 
55 cases lost 3.5 per cent, of mothers and 5.5 per cent, of children. 
Zweifel, of Leipsie, whose former condemnation of the operation has 
already been referred to, in 31 cases lost 4 children and no mothers. 

Bar in 22 cases saved all the mothers and all the children. Kiistner 
in 7 symphysiotomies had no maternal or foetal deaths. In 8 cases 
operated upon by Jewett, 7 of the mothers made good recoveries, 1 died 
of oedema of the lungs a few hours after operation. All the children but 
one were delivered alive, though not all of them survived the first month. 

Indications for the Operation. The field of symphysiotomy has in 
recent years become a very limited one. This is due in part to defects 
inherent in the operation, in part to the steadily improving status of 
Cesarean section. 

Symphysiotomy does not eifect delivery, but merely prepares the way 
for it. The anatomical limitations of the operation are very narrow, 
and exact measurements of the pelvis — and especially of the child's head 
in utero — are impossible. The proper selection of cases for pubic section 
is attended with difficulty and symphysiotomy in a pelvis too small is a 
grave mistake for mother and child. Cesarean section, on the other 
hand, ensures immediate delivery in all cases irrespective of the degree 
of contraction. 

Symphysiotomy, however, may be performed in cases in which the 
operator can be assured that only a little more pelvic space is required 
for delivery. It affords a means of saving both patients in conditions in 
which the judicious use of forceps has unexpectedly failed. Forceps, 
indeed, should always be tried before resort to pubic section. 

It is indicated, too, in certain cases of pelvic contraction within the 
limits already mentioned when the mother is too much exhausted to 
permit abdominal section. Here the prognosis of symphysiotomy is 
good for both patients, while the mortality of the Csesarean operation is 
formidable when performed after long labor or repeated attempts at 
delivery by forceps or version. 

Symphysiotomy is indicated : (1) In simple flat pelves with a conjugata 
vera between 7.5 and 9 cm., 2.8-3^- inches. (2) In generally contracted 
pelves with a conjugata vera between 9 and 10 cm., 3.2-3.9 inches. These 
rules presuppose that the head of the child is of normal size. (3) 
Jewett, with others, finds an application for symphysiotomy. In mento- 
posterior face presentations which are irreducible. (4) In cases of impac- 
tion in occipito-posterior presentations ; version and the employment 

: Neugebauer, 1893, Ueber der Rehabilitation der Schamfugentrennung, etc. 






SYMPHYSIOTOMY. 747 

of the forceps here are often more dangerous to mother and child than 
symphysiotomy. 

Briefly, the operation occupies a field just beyond the scope of forceps. 
Its chief rival in cases of the same degree of pelvic narrowing may be 
said to be embryotomy. In any but slight degrees of pelvic contraction 
it cannot take the place of Csesarean section. Symphysiotomy or the 
Cesarean operation should replace perforation of the living child almost 
wholly. 

Symphysiotomy is contraindicated in ankylosis of one or both sacro-iliac 
joints and by infection of the uterus. In the latter condition Csesarean 
section followed with hysterectomy offers the best chance for the mother. 

Rationale of the Operation. As has been said, the operation depends 
for its success upon the lengthening of the conjugate and the general 
enlargement of the area of the superior strait. When the pubic sym- 
physis, together with the subpubic ligament, is divided and the pubic 
bones are separated from each other, they not only move outward from 
the median line, but also downward in a direction toward the feet. This 
is due to the fact that the axis of rotation at the sacro-iliac joints is not 
parallel to the long axis of the body, but runs from without inward and 
from above downward. 

This peculiarity of rotation has been well explained by Wehle, who 
compares the separation of the pelvic halves very aptly to the opening of 
a pair of double doors. Should the doorposts be vertical and the axis of 
rotation vertical, the under surface of the doors, when opened, will describe 
a plane perpendicular to the axis of rotation and tangential to the earth's 
surface, the lower outer angle of the door neither descending from nor 
approaching the floor ; but should the doorposts be set at an angle from 
above downward and inward toward each other, then the doors, when 
opened, will still describe a plane perpendicular to the axis of rotation, 
but directed in each case from within outward and downward. The 
downward movement of the pubic bones, with the accompanying nuta- 
tion of the sacrum, of itself increases the length of the conjugata vera. 

A separation of 3 cm., 1.1 inches, causes a descent of 2 cm., 0.7 inch, 
and the foetal head pressing upon the ends of the separated bones drives 
them still further downward. Another important thing to keep in 
mind is the fact that the anterior prominent part of the child's head, 
which in the majority of cases is one or other of the parietal promi- 
nences, is received in the space between the sundered bones. We see, 
then, that the canal for the passage of the child is rendered larger in 
three ways: (1) by separation of the ends of the bones, (2) by down- 
ward movement of the ends, and (3) by the accommodation of a promi- 
nent part of the child's head in the interpubic space. With a pubic sep- 
aration of 7 cm., the total gain in the antero-posterior diameter is about 
1.3 cm. ; in the transverse the gain is one and a half, and in the obliques 
about twice as much as in the conjugate. 

Technique of the Operation. The woman should be prepared as for 
an abdominal section. The pubic hair should be carefully shaved, and 
all parts in the neighborhood of the field of operation rendered as aseptic 
as possible. The bladder should be empty. The operation is best de- 
layed, when consistent with safety, until the birth canal has been pre- 
pared by nature as far as possible for the passage of the child. The 



"48 



OBSTETRIC SURGERY. 



cervix should be fully dilated or dilatable and the vagina should be 
ample. If dilatation is not complete it should be made so before 
operation. 

The patient is placed upon her back on the table, with the thighs 
flexed and somewhat everted. This position can be maintained by 
means of a suitable leg-holder. Two assistants must steady the thighs 
and prevent undue separation of the lateral halves of the pelvis after sec- 
tion of the symphysis. The exact situation of the symphysis should be 
determined, and should be indicated by a mark, 1 and it is advisable to 
draw a transverse line showing the situation of the subpubic ligament, 



Fig. 43* 




Fig. 437 




Preliminary incision of the outer cover- 
ing between the recti with the cutting sur- 
face of the scalpel. (Farabeuf.) 



Extending with scissors the opening 
made by the scalpel. (Farabeuf.) 



which can usually be detected easily by the finger below or to one side 
of the clitoris. An assistant introduces a full-sized metallic catheter into 
the urethra. This is depressed as a whole, carrying with it the urethra 
out of the way of the knife ; the catheter serves also at the same time to 
keep the bladder empty. An incision is made beginning about 3 cm., 
1^ inches, above the symphysis and extending downward about three 
inches to the clitoris. The edges of the wound are separated by retract- 
ors, and with a few touches of the knife the linea alba is laid bare. 

1 A fine camel's-hair brush dipped in tincture of iodine or a solution of silver nitrate serves the 
purpose. 



SYMPHYSIOTOMY. 



749 



Fig. 438. 



(Figs. 436 and 437.) When the exact position of the symphysis cannot 
readily be determined, it is well to make gentle traction on the clitoris, 
the suspensory ligament of which is attached to this point and can be 
made to serve as a guide. The next step is to separate the suspensory 
ligament of the clitoris, taking care not to wound the dorsal vessel, and 
to draw the clitoris down and out of the way, until the lower surface of 
the arch of the pubes is brought into view. By careful dissection the 
upper part of the symphysis is next exposed. A finger is then inserted 
between the recti muscles, and the symphysis is freed posteriorly, the 
tissues being pushed away from it. A broad, flat, grooved director or 
guard, strongly bent on the flat, is then inserted under guidance of the 
finger behind the symphysis, either from above downward or from 
below upward. (Figs. 439 and 440.) The function of 
this guard, which should be kept close to the symphysis, 
is to protect the tissues behind it from injury. The sec- 
tion of the symphysis may then be made either from 
within outward (Fig. 441), or, as Farabeuf advises, 
from without inward. Farabeuf uses a short, thin 
knife. (Fig. 438.) The external ligamentary tissues 
are first divided, then the periosteum, and finally the 
cartilage. The periosteum should not be stripped off 
the bone, except for a very short distance. Other 
methods of dividing the symphysis may be preferred. 
After laying bare the joint and opening the linea alba 
between the recti muscles a thin, probe-pointed, nar- 
row-bladed bistoury, passed downward on a finger as a 
guide through the abdominal incision, may be employed 
to sever the joint, the cut being made from behind 
forward. Galbiati's knife, or Harris's modification of 
this instrument, may be used, instead of a bistoury. 
Bleeding is controlled, and a provisional dressing of 
sterilized gauze is packed into and over the wound. 

Avers prefers the following subcutaneous method of dividing the 
symphysis pubis, and reports four successful cases. The procedure is 
somewhat as follows : The clitoris having been raised from the symphy- 
sis, a narrow, sharp-pointed scalpel is passed beneath it through the 
mucous membrane from below upward, in the line of the symphysis, to 
within about half an inch of the upper border of the pubes. The 
tissues of the joint are then cut through with a straight, blunt-pointed 
bistoury. In order that the bladder and urethra should not be injured 
during the procedure they are pushed to one side by means of a sound ; 
at the same time a finger in the vagina controls the blunt point of the 
bistoury while the tissues of the joint are being divided. 

Authorities differ as to whether or not forcible separation of the 
ends of the symphysis should be made. Some French authors, not- 
ably Farabeuf, advise that it be done at once, thus preventing need- 
less compression of the child's head. It would seem more reasonable, 
with Caruso, to support the hips by a sterile bandage and allow the 
process to go on more slowly. This plan is attended with less risk of 
serious laceration of the birth-canal and more nearly approaches the 
conditions attending a normal labor. The pubic bones should not be 



Knife of Farabeuf. 



750 



OBSTETRIC SURGERY. 



allowed to separate further than 6.5 or 7 cm., 2.5-2.7 inches ; if this 
limit be not exceeded, no great harm can be done at the sacro-iliac 
joints. 

It must be kept in mind that while the separation may be within 
these limits, it may be due entirely to the downward and outward 
movement of one side, the other side not partaking in the rotation upon 
the sacral axis. The danger in allowing a larger amount of separation 
than 7 cm., 2.7 inches, lies in the fact that the anterior ligaments of 
the sacro-iliac joints and the tissues in the immediate neighborhood may 
be very extensively ruptured. A small amount of laceration in these 
tissues, as has been said, does no harm. If a separation of 7 cm., 2.7 



Fig. 439. 




Introduction of the finger and of the grooved guard by the suprapubic route. (Farabeuf.) 

inches, or thereabouts is produced, and if this has been accomplished at 
the expense of one sacro-iliac joint, serious disruption may ensue in this 
joint, although the total amount of separation at the symphysis be well 
under the limit. To guard against this the operator should attend per- 
sonally to the separation at the pubes, and see that both ossa innominata 
are equally and gently rotated outward. Should one be rotated further 
out than the other, the situation can readily be detected by observing 
that one pubic end is lower than the other, whereas they should both 
be on the same imaginary line drawn perpendicularly to the long axis 
of the body. Care must be taken, during the passage of the child 
through the pelvis, that the structures anterior to the birth-canal be 
protected with due care, especially if any further operative procedures 



SYMPHYSIOTOMY. 



751 



with the forceps or version be resorted to. It must be remembered 
that the posterior structures have the support of the sacrum, the coccyx, 
and the levator ani, but that those situated anteriorly have practically 
lost their only support. 

During delivery it is well to protect the field of operation, more espe- 
cially the incision and the immediate neighboring parts, from possible 
infection. This can best be done by packing either plain sterilized gauze 

Fig. 440. 




The grooved guard passed behind the symphysis, employed to protect the vessels and organs from 
the knife during the incision. (Farabeuf.) 



or iodoform gauze into and around the wound. This dressing can be re- 
tained in position by a firm, sterile canton-flannel binder. In fact, this 
procedure serves several other ends. The gauze packing in the wound, 
while stopping oozing, or even more active bleeding, gives at the same 
time considerable support of a yielding character to the bladder, urethra, 
and anterior structures. The flannel binder serves to support the ossa 
innominata, and while preventing the divided bones from separating 
too far, allows them to give enough to permit the passage of the child. 



752 



OBSTETRIC SURGERY. 

Fig. 441. 




Symphysiotomy. The division of the symphysis is accomplished (1) by section between the 
recti muscles, to sever as far as possible the hard, creaking bundles of the fibrous covering, and to 
trace in front a line corresponding to the groove of the guard, which is held firmly against the ridge 
corresponding to the articulation behind. (2) By means of a short, narrow blade with a rounded 
extremity the operator then cuts through the symphysis from above downward, with the cutting 
edge of the blade directed forward and under the protection of the grooved guard. (Farabetjf.) 

Extraction with forceps is generally advisable if the child is not 
promptly expelled spontaneously. 



SYMPHTSIO TOMY. 

Fig. 442. 



753 




Mode of introduction of sutures. These should be of strong silk, and should be inserted from 
the ou er borders of the longitudinal bands, keeping close to the bones. It is best to beg' n onX 
right side, which presents the greatest difficulty. (Farabetjf.) 




Tying the sutures, while the bones are held in place by Farabeuf 's forceps. (Farabeuf ) 

48 



754 



OBSTETRIC SURGERY. 



After delivery the wound should be closed. Bone sutures are un- 
necessary and inadvisable. Retention is ensured by suturing the pre- 
pubic fibrous structures and applying a firm pelvic binder, especially 
if coaptation is favored by the use of a trough bed or hammock sling 
during convalescence. 

A simple suture of silk-worm gut embracing all the structures down 
to the bones, or a crossed or figure-of-eight suture of the same material 
may be employed. In the latter plan the deep loop of the suture brings 
together the fibrous structures, and the remaining loop closes the super- 
ficial portion of the wound. 

If preferred, the aponeurotic structures in front of the bones may 



Fig. 4M. 




Ayers' symphysiotomy hammock (.empty), snowing arrangement of canvases, bedpan, etc. 



be brought together with chromated catgut and the rest of the wound 
closed in any of the methods usually practised for the abdominal 
wound. 

If the bladder is ruptured, it should be sutured, and careful after- 
attention given to see that the viscus does not become distended and 
allow the occurrence of extravasation of urine. In such case the com- 
plete or incomplete closing of the external wound must be left to the 
judgment of the operator. 

After the wound has been dressed aseptically the pelvis is encircled 
with two or three firm straps of adhesive plaster which overlap posteriorly. 
A strong canvas binder is then applied, the bony prominences being pro- 
tected with padding. The binder needs constant attention to keep it 
tight. It should be changed if soiled. 



SYMPHYSIOTOMY. 



755 



Pinard uses a gutter-shaped bed or mattress, and places cushions under 
the lateral halves of the body. Jewett and others adopt practically the 
same method, using an ordinary, rather hard mattress and keeping the 
patient on two firm cushions or sand-bags placed under the lateral halves 
of the pelvis and extending nearly to the shoulders. 

When the bedpan is used the greatest care should be exercised by 
the nurse to see that no movement on each other of the anterior ends 
of the bones is permitted. It is best to have ready a strong, intelligent 
assistant to support the pelvis and gently lift the buttocks while the 
nurse slips the vessel beneath. 

An excellent apparatus for maintaining coaptation of the pubic 
bones after symphysiotomy is Ayers' hammock-bed. This consists of a 



Fig. 445. 




Ayers' symphysiotomy hammock, showing patient. Pelvis is supported by upper poles. 
Lower poles and hammock support head, chest, and limbs, and is adjusted to level of upper 
hammock. 



canvas stretcher supported as shown in Figs. 444 and 445. The 
stretcher may be made more or less trough-shaped by the adjustment at 
less or greater distance apart of the poles on which it hangs. A canvas 
sling wide enough to reach well above and below the pelvis is sus- 
pended by its ends from a second pair of poles above the first. When 
adjusted for use the loop of this pelvic sling reaches the stretcher. The 
patient rests with her pelvis in the loop of the sling, while the remainder 
of her body is supported by the stretcher. It Avill be seen that the 
pubic bones are held firmly in apposition by the action of the sling, 
while the upper portion of the body and the lower extremities lie com- 
fortably upon the stretcher. 

In the Dresden clinic patients are provided with a pelvic support, 



756 OBSTETRIC SURGERY. 

and are allowed to get up after three weeks. It would seem that this 
is too early to allow the patient to assume the erect position ; in any 
case, it is wiser to keep her fully six weeks in bed, treating the case as 
one would a pelvic fracture or a fracture of the femur. The pelvic 
support should not be discarded for several weeks after the woman 
leaves her bed. 



INDEX. 



ABDOMEN, ante-partuin examination of, 
213 
contour of, in pregnancy, 131 
enlargement of, in ectopic gestation, 377 
examination of, in accidental hemor- 
rhage, 525 

in placenta prsevia, 518 

in pregnancy, 131 

in transverse presentation, 481. 

in uterine rupture, 510 

value of, 219 
general tenderness of, in ectopic gesta- 
tion, 372 
palpation of, in pregnancy, 132 
pendulous, with prolapsus funis, 498 
preparation of, for cceliotomy, 738 
size of, in pregnancy, 132 
strife of, 132 
tenderness of, in puerperal endometritis, 

607 
value of inspection signs, 132 
Abdominal binder, 247 

in accidental hemorrhage, 526 

in placenta prsevia, 523 

in post-partum hemorrhage, 529 
enlargement in ectopic gestation, 377 
examination for abnormal conditions, 

220 
incision for Cesarean section, 739 

indication for, 735 
intrafcetation, 491 

muscles, action of, during labor, 158 
pregnancy, 360 

signs of, 131 
section in rupture of uterus, 512 
stalk, 85 

wound, closure of, 742 
Abortion, actual, treatment of, 352 
cardiac disease a cause of, 563 
caused by certain drugs, 343 
complete, pathology of, 345 

varieties of, 345 
criminal, 340 
curage vs. curettage, relative merits of 

each, 354 
curettage, technique of, 356 
dangers attending, 350 
definition of, 340 
diagnosis of, 349 
dilatation of cervical canal in induction 

of, 669 
diseases of decidua as cause of, 344 
early, treatment of, 352 
embryonic, 340 
etiology of, 341 
foetal, 340 

causes of, 344 
frequency of, 340 
habitual, 343 f 

treatment of, 350 



Abortion, hemorrhage at night, 347 
incomplete, 345 

varieties of, 345 
in diabetic women, 562 
indications for induction of. 662 
induction of, 661 

Cohen's method, 667 

electricity in, 665 

Hamilton's method, 666 

indications for, 662 

Kiwisch's method, 665 

Krause's method, 666 

Scanzoni's method, 665 

Sch eel's method, 668 

Tarnier's method, 666 
inevitable, treatment of, 352 
involution of uterus after, 349 
late, treatment of, 354 
local causes of, 343 
maternal causes of, 342 
method of inducing, 663 
missed, 358 

fate of retained child, 359 

moles in, 347 

treatment of, 358 
ovular, 340 

paternal causes of, 341 
pathology of, 345 
premonitory signs of, 348 
prognosis of, 350 
prophylaxis in pregnancy, 351 
protracted, 348 
relative size of foetus, 347 
sepsis following, 355 
symptoms and clinical course. 347 
therapeutic, 340 
threatened, treatment of, 351 
time of occurrence of, 341 
treatment of, 350 
tubal, 369 

vs. cervical polypus, differential diagno- 
sis of, 349 
vs. ectopic gestation, differential diagno- 
sis of, 349 
" Abscess de fixation," 626 

mammary, in new-born, 638 
of broad ligament, 608 
of vulva, cause of dystocia, 460 
parametritic, treatment of. 623 
Abscesses, tubal and ovarian, treatment of, 

623 
Acardiacus as a cause of difficult labor. 497 
Accouchement force, 522, 554 

indication for, in cardiac disease 
complicating pregnancy, 565 

in eclampsia, 554 

in placenta prsevia, 523 

in spasmodic contraction of uterus. 
418 
Acetic acid in post-partum hemorrhage, 530 



758 



INDEX. 



Acetone in urine during puerperiurn, 255 
Acini of mammary gland, 67 
Adipocere formation after spurious labor, 381 
Adnexa, changes in, due to pregnancy, 121 
Adrenals, development of, 109 
After-pains, 209 
cause of, 209 
in puerperiurn, 254 
treatment of, 261 
Agalactia, 573 
Air-hunger, 518 
Air, infection from, 598 

injection into intestine, 138 
Albumin in urine, following labor, 255 

test for, 211 
Albuminuria, 398 

a cause of puerperal insanity, 577 
favored by abdominal pressure, 153 
frequency of, 125 
in eclampsia, 537, 542 
in triple pregnancy, 496 
in twin pregnancy, 493 
of pregnancy, 398 
Alcohol in post-partum hemorrhage, 530 

in puerperal infection, 622 
Alcoholism, paternal, a cause of abortion, 

342 
Alimentary tract, development of, 103 
gall-bladder, 107 
intestines, 106 
liver, 106 
mesenterv, 106 
mouth, 103 
oesophagus, 105 
pancreas, 107 
pharynx, 104 
stomach, 105 
tongue, 105 
Allantois, development of, 85 
Amenorrhoea, causes of, 127 
diagnostic value of. 126 
Amnion, anomalies and diseases of, 304 
development of, 84 
dropsv of, 305 
false, 83 
formation of, 83 
true, 83 
Amniotic bands, 308 

fluid, changes in character of, 307 
deficiency of, 304 
excess of, in prolapsus funis, 498 
in version, 702, 704 
removal of, to induce abortion, 668 
sac, pressure of, on cervix, 198 
Amphiaster of ovum, 75 
Ampullae of lacteal ducts, 68 
Anaemia, acute, following post-partum hem- 
orrhage, treatment of, 532 
signs of, 518, 528 
treatment of, 526 
contraindication to nursing, 274 
in post-partum hemorrhage, treatment 

of, 532 
in pregnancy, 406 
Anaesthesia, administration of anaesthetic, 
239 
choice of anaesthetic, 239 
for removal of adherent placenta, 674 
in repair of vaginal lacerations, 653 
in reposition of inverted uterus, 505 
in spinal analgesia, 241 
in version, 702, 708 
obstetric, 238 



Anaesthesia, profound, post-partum hemor- 
rhage from, 257 

to relax uterus, 511 
Anaesthetic in face presentations, 4GS 

in forceps operation, 682 

in occipito-posterior cases, 464 
Anaesthetics, administration of, 239 

choice of, 239 
Anal canal, 41 
Anatomv of anus, 30 

of bladder, 42 

of bulbs of vagina, 25 

of carunculae myrtiformes, 23 

of clitoris, 24 

of cloaca, 44 

of corpus luteum, 53 

of cul-de-sac of Douglas, 30 

of ducts, q. v. 

of Fallopian tubes, 45 

of fascia 1 , q. v. 

of fossa navicularis, 20 

of fourchette, 20 

of glands of Bartholin, 21 
of Uuverney, 21 

of glans clitoridis, 24 

of Graafian follicle, 52 

of hymen, 22 

of ischio-rectal fossa, 30 

of labia majora, 18 
minora, 19 

of ligaments, q. v. 

of mammary glands, 64 

of meatus urinarius, 21 

of mous Veneris, 17 

of muscles, q. v. 

of ovaries, 50 

of paroophoron, 53 

of parovarium, 53 

of pelvic fasciae, 35 
floor, 32 

of perineal body, 41 
ledge, 34 
space, 17 

of perineum, 18 

of recto-vaginal pouch, 30 

of rectum, 30 

of round ligament of uterus, 18 

of the female pelvic organs, 17-70 

of triangular ligaments, 34 

of urethra, 43 

of uterus, 57 

of vagina, 26 

of vessels and nerves of pudendum, 20 

of vestibule, 21 

of vulvo-vaginal glands, 22 

of white line of pelvis, 35 

of Wolffian bodies, 44 
Anencephalus, 489, 496 
Anomalies of amnion, 304 

of foetal appendages. 303 

of placenta, 311 
Anterior commissure, 18 
Anteversion of uterus, 455 
Antihelix, development of, 103 
Antisepsis, chemical agents, 228 

choice of methods of, 230 

effect of, on puerperiurn, 605 

hands of obstetrician, cleansing, 230 

mechanical agents, 228 

obstetric, 227 

precautions, 232 
Antiseptic precautions, 232 
for the nurse, 232 



INDEX. 



759 



Antiseptic precautions in version, 702 

preparation in vaginal examination, 222 
of obstetric patient, 233 
Antitoxin, tetanus, b'43 
Antitragus, development of, 103 
Anus, anatomy of, 30 

congenital malformations of, 629 

development of, 106 

malformations of, in new-born children, 

629 
vaginalis, 460 
Aorta, development of, 91 

maternal, pulsation of, 136 
Aortic bulb, 90 

Apoplexy, diagnosis from eclampsia, 541 
Apptndases, foetal, anomalies and diseases 

of, 303 
Aqueduct of Sylvius, 97 
Aqueous humor, development of, 100 
Arbor vita? uterini, 61 
Arch, branchial, 104 

visceral, 104 
*' Area vasculosa" in embryonic circulation, 83 

of placenta, SS 
Areola, 65 

primary, in pregnancy, 128 
secondary, in pregnancy, 130 
wrinkling of, 130 
Armamentarium, obstetric, 227 
Arms, displacement of, in breech presenta- 
tion, 473 
upward displacement of, in breech pres- 
entations, treatment of, 476 
upwardly displaced, release of, when 
head is below brim, 477 
Arnold pasteurizer for milk, 287 
Arsenic in puerperal insanity, 532 
Arteria centralis retinas, 100 
Arterial tension in pregnancy, 123 
Arteries, allantoic, 92 
aortic arches, 92 

permanent, 92 
carotid, external, 92 

internal, 92 
carotids, common, 92 
dorsal aorta, 92 
ductus arteriosus, 92 
hvpogastric, 93 
iliac, 93 

of Fallopian tubes, 56 
of mammary gland, 68 
of ovaries, 57 
of pelvic floor, 54 
of uterus, 55 
of vagina, 55 
of vulva, 54 
omphalo-mesenteric, 91 
subclavian, 92 
vertebral, 92 
vitelline, 92 
Ascites, cause of dystocia, 491 

differential diagnosis from pregnancy, 

147 
fcetal, obstructing labor, 491 
vs. pregnancy, 147 
Asepsis of the hands, 230, 616 

permanganate method, 231 
means of securing, 228 
Asphyxia in new-born child, causes of, 633 
treatment of, 633 

Byrd's method, 635 
Laborde's method, 636 
Schultze's method, 635 



Aspiration in spina bifida, 627 
Asynclitism, 203 
Atelectasis, 637 
Atresia of cervix, 453 
Atrophy of decidua, 304 
Atropia, oleate of, indication for, 572 
Auditory vesicle, 102 

Auricular canal in embryonic circulation, 90 
Auscultation of abdomen in pregnancy, 134 
Auto-intoxication in eclampsia, 539 
Auto-transfusion, 532 
Axis, parturient, 174 
Axis-traction forceps, 696 
indication for, 691 
with ordinary forceps, 690 

BACILLAEY sepsis, 589 
in puerperal infection, 589 
Bacillus aerogenes capsulatus in puerperal 
infection, 587 
coli communis in puerperal infection, 586 
diphtherias in puerperal infection, 587 
of Doderlein, 29 

typhosus in puerperal infection, 588 
Bacteria in puerperal infection, 584 
Bag of waters, hydrostatic pressure in labor, 

198 
Bags, dilating cervical, method of filling, 

522 
Ballottement, external, 133 
in diagnosis, 133 

in ectopic gestation, 378 

after the fourth month, 
378 
internal, in diagnosis, 144 
Bandl's ring, 511 
Bands, amniotic, 308 
Barley-water in diluting milk, 281 
Barnes' bags, 522, 667 

indication for, 473 
in dilatation of cervix, 669 
in placenta prsevia, 521 
Bartley, incubator, 295 

modification of milk, 282 
test for urea, 212 
Basiotribe, Tarnier's, 730 
Basiotripsy, 723 
Bath of new-born child. 272 
Bathing in pregnancy, 153 
Baudelocque, pelvimeter, 423 
Benzoin, tincture of, for sore nipples, 570 
Bichloride douche in puerperal endometritis, 

621 
Binder, abdominal, 247 

breast, to prevent mastitis, 572 
Birth palsies, 630 
Births, plural, 493 

complex cases, 494 
Bladder, anatomy of, 42 

care of, following operations on pelvic 

floor, 655 
conditions of, obstructing labor, 460 
cystocele, cause of dystocia, 460 
development of, 109 
dilatation of, in foetus, 491 
distended, retention of placenta from, 

672 
distention of, 460 
after labor, 255 
cause of dystocia, 460 
in foetus, 491 

secondary hemorrhage from. 535 
simulating pregnancy, 148 



760 



INDEX. 



Bladder, ectopia vesicae urinaria, 330 

evacuation of, in second stage of labor, 
672 

injuries to, from forceps-operation, 681 

irritability of, in pregnancy, 128 

ligaments of, 37 

maternal, distention of,. 134 

of new-born child, 270 

over-distended vs. pregnancy, 148 

relation to parturient canal, 173 

rupture of, in symphysiotomy, 754 

shape of, 43 

vesical calculus, cause of dystocia, 461 
Blastoderm, development of, 77 
Blastomeres of ovum, 76 
Blebs in puerperal pyaemia, 596 
Blood, amount of, lost in normal labor, 209 

changes in, during pregnancy, 123 

derivation of, 95 

diseases of, an indication for induction 
of abortion, 662 

of new-born child, 269 

primitive erythrocytes, 95 
leucocytes, 95 
Bloodvessels, diseases of, in foetus, 336 
Boiling as a method of sterilization, 229 
Bone, injuries to, in new-born child, 630 
Bony pelvis, obstetric anatomy of. See Labor. 
Boric acid in care of nipples, 568 
Botalli, duct of, 92 
Bougies in induction of labor, 670 
Bowels after labor, 255 

care of, during puerperium, 255 

following operation on perineum, 655 
in pre- eclamptic state, 544 

irrigation of, in anaemia, 533 
in eclampsia, 551 
Brain, aqueduct of Sylvius, 97 

cerebellum, 97 

cerebrum, 97 

corpora quadri genii na, 97 

crura cerebri, 97 

development of, 96 

fore-, 96 

hind-, 96 

injuries in instrumental delivery, 677 

medulla, 98 

mid-, 96 

optic stalks, 97 
vesicles, 971 

pons Varolii, 97 
Branchial arch, structures formed by each, 
104 

arches, development of, 104 

cleft, structures formed by each, 104 

clefts, development of, 104 

pouches, 104 
Braxton-Hicks method of version, 485 
Breasts. See Mammary glands. 

anomalies and diseases of, 567 

care of, in pregnancy, 153 

changes in, in ectopic gestation after 
fourth month, 371 

enlargement of, during pregnancy, 128 

evidence of previous pregnancy in, 151 

mastitis, etiology of, 570 
symptoms of, 571 
treatment of, 572 
abortive, 572 
of suppuration, 573 
prophylactic, 572 

normal structure of, 567 

veins of, 128 



Breech deliveries, paralysis sometimes fol- 
lowing, 631 
delivery in flat pelvis, 434 
impaction of, treatment of, 475 
non-engagement at the brim, manage- 
ment of, 474 
presentation, external version in, 702 
Bregma. See Fontanelles. 
Brim, pelvic, 162 

landmarks of, 162 
plane of, 162 
Broad ligament, haematoma of, in ectopia 

gestation, 374 
Bromides in puerperal insanity, 582 
Bronchi, development of, 107 
Broncho-pneumonia, infectious, 609 
Brow presentation, diagnosis of, 469 
frequency of, 469 
management of, 470 
mechanism of, 469 
Bruit, infantile, 629 
Buckmaster's sling, 227 
Bulbs of vagina, anatomy of, 25 

p^ECUM, development of, 106 
vJ Caesarean section, 736 

absolute indications for, 737 
after-treatment of, 742 
for carcinoma of cervix with preg- 
nancy, 458 
for fibromyoma of uterus with 

pregnancy, 458 
for tumors of vagina obstructing 

labor, 459 
history of, 736 
in bicornate uterus, 453 
indications for 737 

in cardiac disease complicating 
pregnancy, 565 
in eclampsia, 547 
in flat pelvis, 436 
in " funnel-shaped " pelvis, 430 
in kyphotic pelvis, 448 
in malacosteon pelvis, 441 
in obliquely contracted pelvis, 438 
in scoliotic pelvis, 449 
in spasmodic contraction of uterus, 

418 
in tumors of pelvis, 445 
in vaginal enterocele obstructing 

labor, 460 
mortality in, 736 
operation, 738 

instruments for, 738 
points in technique of operation, 742 
preparation for, 738 
relative indications for, 737 
time for performance of, 738 
Calcification of foetus, 334 
Calculus, vesical, dystocia from, 461 
Canal of Nuck, anatomy of, 54 

parturient, enlargement of, in sym- 
physiotomy, 747 
Caput succedaneum, 179, 206 

absence of, with dead foetus, 334 
in brow presentation, 469 
in face presentation, 468 
Carbolic acid solution as an antiseptic, 229 
Carbon dioxide, excess of, in blood a cause 

of labor, 194 
Carcinoma of cervix obstructing labor, 458 
of rectum cause of dystocia, 460 
of uterus cause of dystocia, 458 



INDEX. 



761 



Carcinoma of uterus, hemorrhage from, 534 
Cardiac disease complicating pregnancy, 563 
symptoms and treatment 
of, 564 
in pregnancy, hygienic treatment 
of, 564 
lesions an indication for induction of 
abortion, 662 
Garancnlse myrtiformes, anatomy of, 23 
Casein, effect of excess of, in milk, 289 
of sterilization upon, 287 
human vs. cows' milk, 279 
in milk, 283 

action of, 280 
method of reducing, 283 
Case records, method of keeping, 224 
Catharsis in eclampsia, 551 
Catheterization following repair of vaginal 
lacerations, 655 
indication for, following labor, 259 
method of, 260 
Cauda equina, development of, 99 
Cavity of Eetzius, anatomy of, 43 
Cephalhematoma, 333, 630* 
treatment of, 630 
with large foetus, 487 
Cephalic prominence, foetal, location of, 217 
Cephalotribe, 729 
Cephalotripsy, 729 
Cerebellum, development of, 97 
Cerebral vesicles, primary, 96 
Cervical canal, micro-organisms of, 601 

lacerations, reasons for immediate repair 
of, 660 
Cervix, atresia of, obstructing labor, 453 
carcinoma of, 458 
danger of rapid dilatation of, 549 
deep incision of, in eclampsia, 548 
dilatation of, in eclampsia, 547 
in forceps operations, 683 
in labor, 198 
in uterine inertia, 413 
to induce abortion, 669 
immediate repair of lacerated, 660 
impaction of, 454 
imperfect dilatation of, 555 
incisions of, in rapid delivery, 550 
injuries to, from forceps operation, 681 
lacerated, immediate repair of, 660 
laceration of, method of operation for, 

660 
progressive softening, 198 
rapid dilatation of, in eclampsia, 547 
rigid, treatment of, before rapid deliv- 
ery, 557 
rigidity of, in eclampsia, 550 

in spasmodic contraction of uterus, 

417 
obstructing labor, 453 

treatment of, 454 
rings of, 199 
softening of, 143, 198 
undilated, a contraindication to use of 

forceps, 679 
uteri, anatomy of, 57 

during first stage of labor. 201 
during pregnancy, 121 
mucous follicles of, 121 
Champetier de Eibes' bag, indication for, 
473 
balloon in placenta prsevia, 521 
Changes in maternal organism caused by 
pregnancy, 117-125 



Changes in maternal organism, caused by 
pregnancy, adnexa, 121 
circulatory changes, 123 
external genitals, 122 
gait, 124 

general changes, 122 
nervous system, 125 
nutritional and digestive, 

124 
osseous system, 124 
pelvic floor, 122 

peritoneum, 121 
pelvis, 122 

respiratory cbanges, 123 
skin, 124 

urinary system, 125 
uterus, 117-121 
vagina, 122 
Child, asphyxia of, following forceps deliv- 
ery, 682 
care of, 245 

examination of, at birth, 246 
feces of, 292 

injuries to, in forceps operation, 681 
mortality of, in breech cases, 472 
new-born, anatomy of, 267 
asphyxia of, 633 
bath, 272 
clothing, 273 
cyanosis of, 628 
diseases of, 638 
examination of, 272 
growth of, 271 

heart of, malformations of, 629 
injuries of, 629 

during birth, 629 
to bones and muscles of, 630 
ligation of cord, 271 
malformations of, 627 

rectum and anus, 629 
management of, 271 
normal nutrition of, 291 
physiology of, 267 
respiration of, 271 
weight of, 271 
nursing of, 262 
premature, care of, 293 
incubator for, 294 
weight chart, 292 
Chill in puerperal infection, 607 
Chloasma uterinum, 151 
Chloral hydrate in delayed labor, 415 
in eclampsia, 546 
in puerperal insanity, 582 
in rigidity of cervix, 454 
in uterine inertia, 415 
Chlorinated soda, antiseptic solution, 229 
method of disinfection with, 231 
for sterilizing hands, 231 
Chloroform, administration of, in labor, 239 
in eclampsia, 546 
indication for, 564 
Chorda dorsalis, 81 
Chorion, degeneration of, 310 
diagnosis of, 310 
malignant, 309 

pathology and etiology of, 308 
prognosis of. 310 
symptoms of, 309 
treatment of, 310 
diseases of, 308 
frondosum, 8(? 
in ectopic gestation, 367 



762 



INDEX. 



Chorion lseve, 86 

malignant disease of, 308 
myxomatous degeneration of, 308 
primitive, 83 
Chorionic vesicle, 83 
Choroid, development of, 100 
Choroidal fissure, 100 
Circulation, changes in, at birth, 95 
disorders of, in pregnancy, 405 
embryonic, 88, 95 
foetal, 88 
maternal, changes in, due to pregnancy, 

123 
primitive embryonic, 91 
secondary embryonic, 91 
utero-placental. 87 
Clavicle, fracture of, at birth, 630 
Cleft palate, formation of, 326 
Clitoris, anatomy of, 21 
development of, 113 
Cloaca, anatomy of, 44 

formation of, 107, 323 
Clothing in pregnancy, 153 
of new-born child, 273 
Coagulation ferments in eclampsia, 538 
Cocaine in rigidity of os and cervix, 418 
Cochlea, development of, 102 
Coitus during pregnancy, 154 

over-frequent, as cause of abortion, 343 
Colic in new-born child, 645 
diagnosis of, 646 
treatment of, 646 
Colles' law, 643 
Collver, pelvimeter, 220 
Colostrum, 130, 646 

action of, on child, 257 
composition of, 275 
Colpeurynter, 665 

in cervical dilatation, 671 
Colpocystocele, 460 
Columnse vagi use, 28 
Coma in eclampsia, 537 
Conjunctivitis in new-born child, 641 
Consciousness, loss of, in eclampsia, 537 
Constipation during pregnancy, 405 
Constitutional diseases as cause of abortion, 

342 
Contour of abdomen in pregnancy, 131 
Contractions, intermittent, in diagnosis, 133 
uterine, 133, 142, 195 
cause of pain, 200 
force of, 200 
strength of, 158 
Convulsions in eclampsia, 536 
treatment of, 546 
puerperal. See Eclampsia. 
Cooper, ligaments of, 66 

Cord, umbilical, about the neck, complicating 
version, 718 
anomalies of, 315 

asphyxia from compression of, 633 ' 
care of, 272 

coil of, about the neck, 315 
compression of, 486 
danger of traction on, 672 
injury to, in forceps operation, 681 
insertion of. 315, 517 
interlacing of, in twin births, 495 
knots in, 315 
length of, 315 
ligation of, 271 
position of, 315 
prolapse of, 498 



Cord, umbilical, prolapse of, diagnosis of, 499 
etiology of, 498 
frequency of, 498 
prognosis of, 499 
treatment of, 500 

after rupture of membranes, 
500 
instrumental meth- 
od, 501 
manual method, 
500 
before rupture of mem- 
branes, 500 
reposition of, instrumental method, 
500 
manual method, 500 
shortness of, a cause of dystocia, 486 
a cause of inversion, 503 
diagnosis of, 487 
treatment of, 487 
stenosis of vessels, 316 
strength of, 487 
torsion of, 316 

treatment of, in twin births, 493 
Cords of Pfluger, 111 
Cornea, development of, 100 
Cornual pregnancy, 360 

symptoms, course, and treatment of, 
392 
Corpora quadrigemina, development of, 97 
Corpuscles, colostrum, 275 

red, number and size of, at birth, 269 
Corpus luteum, 254 

anatomy of, 53 
spurium, formation of, 73 
verum, formation of, 73 
Cotyledons of placenta, 86 
Cranial bones, fracture of, in infant, 630 
Cranioclasis, 729 
Cranioclast, 729 
Craniotomy, 725 

and symphysiotomy, 734 
extraction following, 728 
indication for, 511, 723 
is it justifiable on living child, 723 
method of operating, 726 
on after-coming head, 734 
technique of, 725 
Cranium of new-born child, 267 
Cream mixtures, Gartner, 286 
Monti, 285 
Eotch, 284 
Vigier, 284 
Crede's method in treatment of adherent 
placenta, 674 
of retained placenta, 672 
of expelling placenta, 618 
of expression of placenta, 244 
Creolin solution as an antiseptic, 230 
Cristas vaginas, 28 
Crura cerebri, development of, 97 
Crushing operations, 733 
Cul-de-sac of Douglas, anatomy of, 30 
Cultures of bacteria from uterus, 613 

from vagina, 601 
Curage in abortion, 353 
Curettage for abortion, dangers of, 357 
in abortion, 353 
operation of, technique of, 356 
Curette in puerperal endometritis, 520 
Cuvier, ducts of, 93 
Cyanosis neonatorum, cause of, 96, 628 
Cyst, cause of dystocia. 460 



INDEX. 



763 



Cyst, ovarian, resembling pregnancy. 147 

Cystocele, 460 

Cysts of Morgagni, 50 

of placenta, 314 

DEATH, foetal, diagnosis from asphyxia, 
637 
of large foetus, indication for embry- 
otomy. 723 
Decapitation, 730 

-hook, Braun's 731 
indication for. 497 
in transverse presentations, 486 
Decidua. atrophy of, 304 
diseases of, 303 

a cause of abortion. 343 
imperfect development of, 304 
in ectopic gestation, 365 
menstrualis, 71 
reflexa. formation of. 86 
serotina, formation of, 86 
vera, formation of. 85 

loosening of, in labor, 194 
Decollation in locked twins, 733 
Decollator, Braun's, 731 
Deformities, pelvic, detection of, 220 

in different races, 172 
Delivery after embryulcia, 479 
rapid, bimanual method. 557 

dangers of, with rigid cervix, 558 
in pre-eclamptic state, 545 
methods of, in eclampsia, 547 
recent, positive signs of, 265 
probable signs of, 266 
uncertain signs of, 266 
Dental caries in pregnancy, 405 
Development of. alimentary tract, 103 
of clitoris, 113 
of external genitals, 112 
of foetus, at various months, 114-116 
of heart, 89 
of nose, 105 
of penis, 113 
of parovarium, 111 
of pulmonary organs, 107 
of sexual organs, 44 
of skeleton, 113 
of urogenital system, 107 
of uterus, 111 
of vagina. Ill 
of vulva, 113 
Diabetes complicating pregnancy, 562 

diagnosis, prognosis, and treat- 
ment of, 562 
Diagnosis of pregnancy, 126 
Diameter, of Baudelocque, 221 
bisischial, of pelvis, 170 
diagonal conjugate, measurement of, 223 
external conjugate, 170, 221 

in spondylolisthetic pelvis, 443 
foetal, bimastoid, 178 
biparietal, 178 
bitemporal, 178 
cervico-bregmatic, 178 
fronto-mental, 178 
occipitofrontal, 178 
occipito-mental, 178 
suboecipito-bregmatic, 178 
suboccipito-frontal, 178 
intercristal, measurement of, 222 
pelvic, external conjugate, 170, 221 
oblique, 170 
intercristal, 170, 222 



Diameter, pelvic, internal conjugate, meas- 
urement of, 742 
interspinal, 170 

pubo-coccygeal, measurement of, 223 

sacropubic, measurement of, 223 

transverse, measurement of, 223 

true conjugate, measurement of, 222, 223 
Diameters, external, of pelvis, 170 

in spondylolisthetic pelvis, 443 

of foetal head, 178 
Diaphoresis in eclampsia, 551 

in pre-eclamptic state, 544 
Diarrhoea in pregnancy, 405 
Diet in pre-eclamptic state, 543 

in pregnancy, 152 

in preventive treatment of eclampsia, 
542 

in vomiting of pregnancy, 404 

mother's, while nursing, 274 
Digestion, changes in, during pregnancy, 124 

disturbances of, in pregnancy, 399 

following labor, 257 

of new-born child, 269 
Digestive juices at birth, 270 

organs during pregnancy, 152 

maternal, changes due to pregnancv, 
124 

system in new-born child, 269 
Dilatation of cervix, digital, 671 

of os uteri, rapid methods of, 559 
Dilator, Barnes', in rigid cervix, 454 

for cervix, 669 
Diseases, constitutional, affecting placenta, 
524 

contagious, during pregnancy, 155 

of amnion, 304 

of chorion, 308 

of foetal appendages, 303 
Disinfection of hands, 616 
Dislocation of femora affecting pelvis, 444 
Diuresis in eclampsia, 551 

in pre-eclamptic state, 544 
Douche, bichloride, death from, 621 

during puerperium, 619 

hot, in delayed labor, 416 

in puerperal endometritis, 620 

intra-uterine, indication for, 674 
in post-partum hemorrhage, 531 
in puerperal infection, 620 

vaginal, following repair operations, 659 
Drainage in Csesarean section, 742 
Dropsy, amniotic, dyspnoea from, 124 
Drugs as cause of abortion, 343 

during pregnancy, 155 

for induction of premature labor, 670 

in nausea and vomiting of pregnancv, 
404 

in puerperal insanity, 582 
Duct, cystic, malformations of, 640 

galactophorous, 67 

of Botalli, 93 

of Cuvier, 93, 94 

of Gartner, 111 

of Muller, 44, 109 

of Wolff, 107, 110 
Ducts, hepatic, development of, 107 

Mullerian, 109 
Ductus arteriosus, 92, 269 

Botalli. See Ductus arteriosus. 

communis choledochus, development of, 
107 
malformations of, 640 

venosus, 95 



764 



INDEX. 



Duties, final, of physician after labor, 247 
Dwarfs, pelvis in, 427 
Dyspnoea during pregnancy, 123 
in hydramnios, 305 
in pregnancy, 407 

from heart lesions, 564 
Dystocia, caused by ascites, 491 

by bladder distention, 460 
by brow presentation, 465 
by calculus, vesical, 461 
by cervix, atresia of, 453 
impaction of, 454 
rigidity of, 453 
by encephalocele, 488 
by enterocele, 460 
by face presentation, 465 
by foetus, anomalies of, 462, 486 
emphysema of dead, 487 
enlargements or dilatations, 492 
of head or bodv by disease, 
488 
large size of, 487 
by hernia, inguinal or crural, 462 
by hydromeningocele, 488 
by hydrothorax, 491 
by kidney, floating, 462 
by limbs, prolapse of, 486 
by monsters, 496 

double, 495-497 
by pelvic presentations, 470 
by plural births, 493 
by rectum or colon, distention of. 460 
by skull, unduly ossified, 487 
by transverse presentation, 480 
by triplets, 496 
by tumors, solid, of vagina or vulva, 

460 
by uterus, anteversion of, 455 
nbromyorna, 456 
in hernial sac, 455 
latero-version, 456 
polypus of, 458 
prolapse of, 456 
sacculation of, 456 
by vulva, abscess of, 460 
oedema of, 459 
stenosis of, 459 
varicosities of, 459 
classification of, causes of, 409 
definition of, 409 
prevention of, 452 

EAE, development of, 102 
external, development of, 102 
middle, development of, 102 
Ecbolics, 663 

Eclampsia, causes of, exciting, 540 
of foetal death in, 541 
of maternal death in, 541 
predisposing, 540 
curative treatment of, 545 
definition, 536 
diagnosis of, 540 

differential, from apoplexy, 541 
from epilepsy, 540 
from hysteria, 540 
from meningitis, 541 
effect on foetus, 537 
elimination of poison, 550 
emptying the uterus in, 546 
etiology of, 537 
frequency of, 536 
indication for use of forceps in, 680 



Eclampsia in twin pregnancy, 349 
pathology of, 540 
prodromal period of, 536 
prognosis of, 541 
stage of coma, 537 
of invasion, 536 

of tonic and clonic convulsions, 536 
symptomatology of, 536 
theories concerning cause of, 357 
treatment of, 541 
curative, 545 
preventive, 542 
Ectoderm, development of, 78 
of ovum, 78 

tissues developed from, 79 
Ectopia cordis, cause of, in development, 327 
Ectopic gestation, 360 

abdominal enlargement, 377 

pregnancies without rupture, 
376 
anomalous varieties of, 360 
ballottement in, 378 
changes in breasts, 377 

in placenta, 369 
concurrent with uterine gestation, 

391 
definition of, 360 
diagnosis of, 371 

after fourth month, 376 
of intraperitoneal rupture, 372 
prior to fourth month, 371 
differential diagnosis from abortion, 

349 
disturbances of menstruation, 371 
earlv primary rupture, treatment 

of, 383 
etiology of, 363 
extraperitoneal rupture, 374 
false or spurious labor in, 380 
general conclusions, concerning 

signs and diagnosis, 378 
hematocele, 372 

hematoma in broad ligament, 374 
intraperitoneal rupture, 372 

treatment of, 383 
movements of foetus, 377 
near full term, treatment of, 386 
pathology of, 365 
pelvic pain in, 371 
placental souffle, 378 
presence of mass in pelvis. 371 
primary extra-peritoneal rupture, 
hematoma, 374 
intra-peritoneal rupture, 372 
prior to fourth month, general con- 
siderations, 371 
repeated, 391 
secondary rupture, 375 
sepsis in, treatment of, 385 
subperitoneal rupture, treatment 

of, 390 
symptomatology, after the fourth 
month, 376 
prior to fourth month, 371 
traumatic, 392 
treatment of, 382 

after fourth month, foetus in 
abdominal cavity, 389 
subperitoneal, 390 
general considerations, 386 
in septic cases, vaginal inci- 
sion, 385 
unruptured tube, 388 



INDEX. 



765 



Ectopic gestation, treatment of, prior to 
fourth month, after rupt- 
ure, extra-peritoneal, 384 
before rupture, 382 
general considerations, 382 
intra-peritoneal, 383 
secondarv rupture, 385 
after rupture, 383 
before rupture, 382 
twin, 391 

unruptured tubal pregnancy, 376 
utero-abdominal or traumatic, 392 
vaginal incision in, 382 

in septic cases, 385 
varieties of, 360 

with foetus in abdominal cavity, 
treatment of, 389 
in unruptured tube, treat- 
ment of, 388 
subperitoneal, treatment 
of, 390 
Egg-albumin in milk foods, 290 
Electricity in inducing abortion, 665 
Embolism following induction of abortion, 

668 
Embrvo, at different periods of development, 
"114 
circulation of, 95 
development at first month, 114 
folding off of, 82 
head-folds, 82 
lateral folds, 82 
nourishment of, 86 
size of, at second month, 115 

at third month, 115 
stages in development of, 114 
tail-folds, 82 
Embryotome, 723 
Embryotomy, defined, 723 
indication for, 511 

in spasmodic contraction of uterus, 418 
or Cesarean section, 735 
prognosis of, 724, 735 
technique of, 725 
Embryulcia, 486 

for tumors of vagina obstructing labor, 

460 
in bicornate uterus, 453 
in breech presentations, 479 
indications for, 468, 475, 487, 495 
in flat pelvis, 436 
in funnel-shaped pelvis, 430 
in obliquely contracted pelvis, 438 
in tumors of pelvis, 446 
Eminence, ilio-pectineal, 162 
Emotional influences in labor, 201 
Emphysema of dead fetus, cause of dys- 
tocia, 487 
Encephalocele, 627 

cause of dvstocia, 488 
Endocarditis in foetus, 336 
Endometritis, chronic, adherent placenta 
from 672 
diffuse decidual, 303 
" diphtheritic," 591 
during puerperium, 265 
gonorrhceal, 622 
mixed infection, 599 
puerperal, 591 

treatment of, 619 
putrid form, symptoms of, 608 
septic, 507 
Endometrium, formation of, after labor, 253 



Enema, administration of, following opera- 
tions on perineum, 659 
saline, in eclampsia, 551 
Enterocele, cause of dystocia, 460 
treatment of, 460 
vaginal, 460 
Entoderm, development of, 110 
of ovum, 78 

tissues developed from, 80 
Epididymis, development of, 110 
Epiglottis, development of, 107 
Epilepsy a contraindication to nursing, 274 
diagnosis from puerperal eclampsia, 540 
Episiotomy in oedema of vulva, 459 

operation of, 243 
Epoophoron. See. Parovarium. 
Ergot a cause of abortion, 343 
of uterine rupture, 509 
after removal of adherent placenta, 674 
ecbolic action of, 663 
in abortion, 663 
in accidental hemorrhage, 526 
in delayed labor, 416 
indication for, 565 
in placenta prsevia, 524 
in post-partum hemorrhage, 529 
in uterine inertia, 416 
use of, in third stage of labor, 245 
Esbach's test for albumin, 211 
Eustachian tube, development of, 102 
Eustachius, value of, 95 
Eutocia, definition of, 192 
Evisceration, indication for, 492 
in locked twins, 733 
in transverse presentations, 486 
Evolution, spontaneous, in transverse pres- 
entations, 483 
Examination, abdominal, in abnormal con- 
ditions, 220 
in labor, 235 
method of 136 
record of, 225 
ante-par turn, 213 
record of, 225 
bimanual, in ectopic gestation, 378 
in pregnancy, steps of. 126 
obstetric, abdominal, 213 
objects of, 155 
preparation for, 131 
of child, new-born, 272 
pelvic, during puerperium, 265 

method of, 138 
rectal, during labor, 618 
vaginal, 222 

during labor, 237 
during pregnancy, 153 
in labor, 235 

frequency of, 236 
in uterine inertia, 414 
presence of mass in ectopic ° - esta- 

tion, 371 
record of, 225 
Exercise in pregnancy, 153 
Exhaustion from prolonged labor, a cause of 

post-partum hemorrhage, 527 
Exomphalos, 492 

Exostoses as cause of pelvic deformity. 415 
Expelling powers in labor, 157 
Expulsion of foetus, mechanism of, 201 
External genitals, changes due to pregnancy, 

122 
Extraction in craniotomy. 728 
in symphysiotomy, 752 



GG 



INDEX. 



Extra-uterine pregnancy. See Ectopic ges- 
tation. 
Extremities, development of. 113 

first appearance of, 114 
Eye. development of, 99 
Eyelids, development of, 101 

FACE presentations, 465 
abnormal conditions in, 467 
diagnosis of, 466 

from breech, 472 
etiology of, 465 
frequency of, 465 
bead moulding in, 468 
management of, 468 
mechanism of, abnormal, 467 

normal, 467 
mento-posterior, indication for sym- 
physiotomy in, 746 
positions, relative frequency, 465 
prognosis of, 466 
Facial paralysis, from forceps operation, 681 

in new-born child, 630 
Fainting in pregnancy, 406 
Fallopian tubes, anatomy of, 45 
blood-supply of, 56 
changes in ectopic gestation, 365 
development of, 111 
fimbriae of, 48 

mucosa in ectopic gestation, 363 
mucous lining of, 50 
nerves of, 57 

pathological conditions favoring ec- 
topic gestation, 364 
vessels of, 56 
Fallopius, tubes of, 111 
Faradism for tardy involution, 265 
in birth paralyses, 631 
in post-parturn hemorrhage, 532 
Fascia, anal, 40 
obturator, 35 
pelvic, 35 

vesical layer of, 35 
recto- vesical, 35 

function of, 650 
superficial, of perineum, 33 
Fat, comparison of, in human and cows' 
milk, 279 
deficiency of, in milk, 290 
human vs. cows' milk, 279 
in milk, effect of sterilization on, 286 
method of increasing, in milk, 282 
Feces of the infant, 292 
Feeding of infant, amount of, 290 
artificial, 278 
bottle, 278 
cream mixtures, 284 
forced, 291 
frequency of, 290 
mixed, 278 
modified milk, 281 
nursing-bottle, 290 
peptonized milk, 284 
requirements of substitute food, 

279 
table of age interval and amount, 
291 
of frequency and quantity, 277 
variation of food-elements in milk, 
289 
of new-born child, precautions in, 647 
premature child, 297 
substitute, 278 



Fertilization of ovum, 75 
Fibroid, submucous, resembling pregnancv. 
144 
tumor of uterus resembling pregnancy, 
147 
Fibroma, uterine, secondary hemorrhage 

from, 534 
Fibromyoma of uterus, a cause of dystocia, 
456 
obstructing labor, 456 

treatment of, 457 
with pregnancy, diagnosis of, 457 
Filum terminale, 98 
Fimbria ovarica, 49 
Fissures of nipples, 568 

treatment of, 568 
Flexion of foetal head in labor, 202 
Foetal anomalies, production of, 335 

appendages, anomalies and diseases of, 
303 
development of, 82 
death, 637 
development, anomalies of, obstructing 

labor, 486 
exhaustion an indication for use of for- 
ceps, 680 
head, abnormal occipito-posterior posi- 
tions of, 463 
approximate diameters of, 179 
bones of, 175 
changes in diameters of, in labor, 

180 
circumference of, 179 
compression of, with forceps, 677 
detached from trunk, delivery of, 

696 
determination of position of, pre- 
vious to forceps operation, 683 
diameters of, 178 

estimation of size of, prior to ap- 
plication of forceps, 678 
extension of, in labor, 204 
external rotation of, 206 
large, in eclampsia, 540 
lateral inclination of, in labor, 203 
moulding of, 207 

in flat rachitic pelvis, 434 
in labor, 179 
obstetric anatomy of, 175 
occipito-posterior position of, 462 
palpation of, 216 
planes of, 179 
protuberances of, 177 
restitution of, in labor, 206 
rotation of, experiment of Dubois, 
203 
of Edgar, 203 
size of, for application of forceps, 

679 
sutures of, 175 

unengaged, a contraindication to 
use of forceps, 679 
infection, 333 
movements, 133 

parts, palpation of, in abdominal exami- 
nation, 132 
pole, lower, palpation of, 214 

upper, palpation of, 216 
shock, 138 
Foetus, abnormalities of, 318 

anomalies of, abnormally large single 
parts, 329 
developmental, abrachius, 321 



INDEX. 



767 



Foetus, anomalies of. developmental, absence 
of internal organs, 321 

or malformation of pelvis 
and extremities, 3*21 

or stunting of large sections 
of body, 317 
of separate parts, 317 

partial, of beart, 323 
acardiacus amorpbus, 317 
acepbalus, 317 
acbeilia, 321 
acormus. 317 
acrania, 317 
acromegalic, 329 
aglossia, 321 
agnathia, 319 
amelus, 321 
amorpbus, 317 
amyelie, 321 
anomalous position of parts or 

organs. 330 
aprosopus, 320 
apus, 321 
arrested development, meta- 

morpbosis, 323 
arrest of development, 325 
atresia?, 32S 
causes of dystocia, 462 
cleavage, 325 

cranial and vertebral, 326 

intestinal, 327 

of cbest and abdomen, 327 

of lips, jaw, and palate, 326 

vesical, 327 
cloaca formation, witb abdom- 
inal and vesical 
cleavage, 327 
with closed bladder, 327 
with vesical cleavage, 
327 
club-foot, varieties of, 328 
congenital luxations, 328 
craniopagus, 329 
cranioschisis, 326 
cretinismus, 318 
cryptorchismus, 328 
cyclopia, 318 
dextrocardia, 330 
dicephalus, 329 
diprosopus, 329 
dipygus, 329 
diverticula, 328 
diverticulum, Meckel's, 328 
duplication of upper and lower 

ends of bodies, 329 
dwarfs, 323 

dystopia? of separate organs, 330 
ectopia cordis, 330 

vesicae urinaria?, 330 
engastrius, 330 
epigastrius, 330 
epignathus, 330 
epispadias, 327 
fistula coli congenita, 326 
fcetus in fcetu, 330 
from arrested development, 323 
fusion of kidneys, 323 
gastroschisis, 327 
genital organs, arrested develop- 
ment of, 324 
giants, 329 
hare-lip, 326 
hemicrania, 317 



Fcetus, anomalies of, developmental, her- 
maphroditism, 324 
hermaphroditites, 324 
hernia peritonealis congenita, 

327 
hydrencephalocele, 326 
bydrencephalus, 329 
hydrocephalus, 329 
hypertrichiasis, 329 
ischiopagus, 329 
janiceps, 329 

luxations, congenital, 328 
macrocephalus, 329 
macrodactylia, 329 
macroglossia, 329 
macrosomia, 329 
malformations of face, 320 

of vertebral column, cord, 
chest, 320 
microbrachius, 321 
microcephalus, 317, 323 
micromelus, 321 
micropus, 321 
microsomia, 323 
monobrachius, 321 
monopus, 321 
monstra duplicia, 329 

per defectum, 317 

per excessum, 329 

per fabricam alienam, 330 

triplicia, 330 
mylacephalus, 317 
nansomia, 323 
of heart, 323 

organs, absence of, 321-323 
over-large development, 329 
pathology of, 317 
perobrachius, 321 
peromelus, 321 
peropus, 321 
pbocomelus, 321 
polydactylie, 330 
polymelia, 330 
prosopothoracopagus, 329 

parasiticus, 320 
pyopagus, 329 
rachipagus, 330 
rachischisis, 326 
single parts, abnormallv small, 

323 
situs transversus, 330 
spina bifida, 326 
supernumerary extremities, 330 

formation, 329 

organs, 330 

polydactylie, 330 

polymelia, 330 
sympus, 321 
syncephalus, 329 
syren formation, 321 
talipo-manus, 328 
terata anacatadidyma, 329 

anadidyma, 329 

catadidyma, 329 
thoracopagus (Siamese twins), 

329 
thoracopus parasiticus. 330 
uterus duplex, 325 

unicornis, 325 
appendages of, development of. 82 
at different periods of development. 114 
attitude of, 191 
calcification after spurious labor. 3S1 



768 



INDEX. 



Foetus, cerebral hemorrhages in, 333 
circulation, 88 

circumference of head of, 179 
conditions of, indicating forceps, 680 
dead, absorption from, 487 

a contraindication to use of forceps, 
679 

emphysema of, 487 
death of, 637 

an indication for induction of abor- 
tion, 662 

calcification, maceration, mummifi- 
cation, putrefaction, 334 

diagnosis of, 334 

in placenta prsevia, 519 
delivery of trunk of, 206 
descent of, in labor, 120, 201 
development of, at first month, 114 
diagnosis of death of, 334 
diseases of, 332 

cephalbsematoma, 333 

classification of, 332 

foetal infection, 333 

heredity, 332 

inflammation of, 333 

primae vise, 337 
effect of eclampsia upon, 537 
enlargement of head or body of, by dis- 
ease, 488 
errors in development of, 334 
flexion of head of, in labor, 202 
head, circumference of, 179 

diameters of, 177 

measurements of, 177 

mobility of, 180 

moulding of, 179 
in labor, 207 

obstetric anatomy of, 175 

planes of, 179 
heart, auscultation of, 218 

diagnosis of location of, 218 
heart-sounds of, 134, 136 
hemorrhage of, 333 
hereditary disease of, 332 
infectious diseases of, 333 
inflammation of, 333 
in uterine inertia, 414 
large size of, cause of dystocia, 487 
length of, in last months of pregnancy, 

151 
location of back and small parts of, 213 
malnutrition of, 334 
malposition of head of, obstructing 

labor, 462 
management of birth of trunk, 243 
mature, length of, 180 

weight of, ISO 
mensuration of, in determining date of 

labor, 150 
method of expulsion, 201 
mortality of, in precipitate labor, 412 
moulding of, in breech presentations, 

473 
movements of, in diagnosis, 133 

in ectopic gestation, 377 
mummification after spurious labor, 381 
palpation of, in pregnancy, 144 
papyraceus, occurrence of, 300 
parts of, in diagnosis, 132 
pathology of 317 
rotation of bead of. in labor. 203 
size of, at different stages, 115 
svstemic organic lesions, 335 



Foetus, table of length, 151 

treatment of anomalies of, obstructing 

labor, 492 
trunk, diameters of, 180 
viability of, 340 

weight as a criterion, 340 
weight of, 487 

at different stages, 115 
Folding off of the embryo, 82 
Follicles of Montgomery, 130 
Fontanelles, 175 
at birth, 267 
closure of, 487 
false, 177 
Food, nitrogenous, in pre-eclamptic state, 

543 
Foramen of Munro, 97 
ovale, 95, 268 

closing of, at birth, 96 
Forceps, 675 

application of, 684 

in flat pelvis, 435 

to after-coming head, 695 

to breech, 695 
ax is -tract ion, 696 

advantages of, 698 

Breus', 699 

Galabin's, 696 

Hubert's, 696 

indication for, 465, 695 

in obliquely contracted pelvis, 438 

Jewett's, 698 

Lusk's, 698 

operation with. 699 

Tanner's, 697 ' 
blades, removal of, 675 
cephalic application of, 687 
Chamberlen, 675 
contraindication to use of, 678 
extraction with, for prolapse of cord, 501 

high operation, 689 

in median operations, 693 

low operation, 688 
function of, 677 
handles of, 675 
high application of, in occiput-posterior 

cases, 464 
in breech cases, 695 

indications for, 468, 493, 501, 511, 525, 679 
in face presentation, 695 
in funnel-shaped pelvis, 430 
in justo-minor pelvis, 429 
in occipito-posterior positions, 693 
in pelvic presentations, 478 
in uterine inertia, 417 
invention of, 675 
lock of, 676 
low application of, in occiput-posterior 

cases, 465 
obstetric, 675 

application of, 684 

Barnes', 677 

blades of, 676 

Braun's, 677 

cephalic curve of, 676 

compression with, 678 

contraindication to use of, 678 

direct traction with, 678 

Dubois', 677 

fenestration of, 676 

function of, 677 

handles of, 675 

Hodge's, 677 



INDEX. 



769 



Forceps, obstetric, indications for use of, 679 
Jewett's. b'?7 
lever action of, 678 
Levret's, 677 
lock of, 676 
material of, 676 
Naegele's, 677 
Pajot's, 677 
pelvic curve of, 676 
prerequisites to use of, 678 
rotative action of, 678 
shanks of, 676 
short, straight, 676 
Simpson's, 677 
Wallace's 677 
■operation, 634 

amount of tractile force in, 691 

cephalic application, 687 

dangers of, 631 

extraction in, 637 

general rules in, 692 

high, 684 

introduction of first blade, 685 

of second blade, 636 
line of pull in, 690 
locking, 686 
low, 684 
median, 634 

posture of patient in, 683 
preparation for, 632 
steps of, 635 
traction in, 683 
Palfyn, 675 

paralysis caused by pressure of, 631 
pelvic application of, 635 
Poullet's, 696 

rupture of symphysis pubis from, 512 
shanks of, 676 
Smellie's, 675 
to after-coming head, 695 
value of, compared with symphysiotomy 

and version, 721 
with malacosteon pelvis, 441 
Fore-gut, development of, 82 
Fornix of vagina, 26 
Fossa, ischio-rectal, anatomy of, 30 

navicularis, anatomy of, 20 
Fourchette, anatomy of, 20 

rupture of, 651 
Frsenulum, anatomy of, 19 
of labia minora, 19 
pudendi. See Fourchette. 
Freeman pasteurizer for milk, 287 
Frontal protuberance, 177 
Fundus uteri, anatomy of, 58 

location of, by abdominal examina- 
tion, 132 
Funis, presentation of, 498 

reposition of, 500 
Fiirbringer method of disinfection, 231 



GAIT, changes in, due to pregnancy, 124 
Galactocele, 574 

treatment of, 574 
Galactorrhoea, 574 
Gall-bladder, development of, 107 
Gartner, duct of, 111 

modification of milk, 286 
Gavage in infant feeding, 291 
Gelatin-water in diluting milk, 279 
Genital fold, 110 
groove, 112 

49 



Genital labium, 112 

organs, diseases of, in foetus, 338 

tubercle, 112 
Genitalia, care of, in puerperium, 261 

diseases of, in foetus, 338 
Genitals, cleansing of, for forceps operation, 
682 

external, development of, 112 
during pregnancy, 122 
Germinal epithelium, 110 

spot, 74 

vesicle of ovum, 74 
Gill arches. See Branchial arch. 

clefts. See Branchial clefts. 
Glands, Bartholin's, anatomy of, 21 

Duverney's, 21 

mammary, anatomy of, 64 

of Montgomery, anatomy of, 64 

Skene's, anatomy of, 44 

thymus, development of, 104 

vulvo-vaginal, 22 
Glandulse vestibuli minores, 21 
Glaus clitoridis, anatomy of, 24 
Glonoin in eclampsia, 551 
Glottis, development of, 107 
Gloves, operating, 232 
Glycosuria during pregnancy, 562 
Gonococcus in puerperal infection, 585 
Graafian follicle, anatomy of, 52 
development of, 72 

HEMATOCELE in ectopic gestation, 372 
Hsematoma of broad ligament, 374 
of vagina, 513 
of vulva, 573 
of vulva and vagina, 513 
cause of dystocia, 459 
symptoms and treatment of, 514 
Hsematometra, 134 

simulating pregnancy, 148 
Haemophilia, post-partum hemorrhage caused 
by, 527 
prenatal, 333 
Haines' method of computing urinary solids, 

211 
Hammock-bed, Ayres, 513, 755 
Hand, prolapse of, 482 
Hands, cleansing of, 230, 682 

disinfection of, 616 
Hare-lip, formation of, 326 
Hart's law, 467 
Head-bend, primary, 96 

Head, constriction of, by uterus in breech 
presentation, 477 
delivery of, in podalic version, 719 
extraction of, in breech cases (Smellie 

method), 478 
forceps extraction of, in breech presen- 
tation, 478 
impaction of, in breech presentation, 

473, 478 
malrotation of, in breech presentation, 

480 
manual extraction of, in breech pres- 
entation, 478 
-moulding, absence of, in ossified skull, 
487 
in brow presentation, 469 
in contracted pelvis, 429 
in face presentation, 468 
in justo-minor pelvis. 429 
in occiput-posterior eases, 463 
occiput posterior, cause of dystocia, 462 



770 



INDEX. 



Heads, foetal, detection of, in multiple preg- 
nancy, 302 
Heart, anomalies of development, 323 
auricular canal of, 90 
cardiac disease, complicating pregnancy, 
563 
treatment of, 564 
changes in, during pregnancy, 123 
development of, 89 

of foramen ovale, 91 
of septum infer i us, 91 

superius, 90 
of truncus arteriosus, 91 
diseases of, in foetus, 336 
embryonic, size of, at first month, 115 
foetal, causes of inaudibility of, 136 
examination of, 136 
heart-sounds in pregnancy, 134 
location of, 218 
sounds of, 134 
infantile, congenital malformations of, 

628 
lesions of, in pregnancy, 563 
malformation of, in new-born, 628 
of new-born child, 268 
palpitation of, in hydramnios, 305 
physiological hypertrophy of, 563 
-sounds, feebleness of, 306 
foetal, 115 

in pelvic presentation, 471 
in transverse presentation, 482 
two, in plural pregnancy, 302 
stimulants, use of, in cardiac disease 

cornpnicating pregnancy, 565 
symptoms of valvular disease of, 564 
valvular disease of, complicating preg- 
nancy, 563 
Heat, dry, for antisepsis, 228 
moist, for antisepsis, 228 
Hegar's sign in diagnosis, 140 
Helix, development of, 103 
Hemicephalus, 489 
Hemiplegia, from forceps operation, 681 

in newborn infant, 632 
Hemispheres, cerebral, development of, 97 
Hemorrhage, accidental, 516, 524 
apparent, 525 

diagnosis from placenta praevia, 

518, 525 
diagnosis of, 525 

525 
etiology 525 
prognosis of, 525 
treatment of, 525 
varieties of, 524 
concealed, 525 
as cause of abortion, 345 
at night onlv in certain cases of abor- 
tion, 347 
cerebral, in newborn infant, 632 
following abortion, 350 
from circular artery, 660 
from uterine contractions, 194 
in abortion, 347 
in ectopic gestation, 368, 379 
in foetus, 333 
in foetal disease, 336 
in hydramnios, 306 
in placenta pnevia, 516 
control of, 520 
in thrombosis of vulva, 513 
intracranial, at birth, 630 

from forceps operation, 681 



Hemorrhage of placenta prsevia, 516 
post-partum, 529 
etiology of, 527 
frequency of, 527 
in placenta prsevia, 523 
in twin births, 493 
preventive treatment of. 529 
relation to pelvic deformity, 452 
secondary treatment of, 533 
symptoms and prognosis of, 528 
treatment of, active, 529 

prophylaxis. 529 
with justo-major pelvis, 427 
with tumors of uterus, 457 
renal, in foetus, 338 
secondary post-partum, 533 
source of, 516 
umbilical, in child, 638 
unavoidable, 516 
uterine, 516 

demanding use of forceps, 680 
following precipitate labor, 414 
in false labor, 406 
on death of foetus, 358 
varieties of, 516 
Hemorrhagic diathesis, post-partum hemor- 
rhage from, 528 
Hemorrhoids in pregnancy, 406 
Hepatitis, interstitial, 640 
Heredity in diseases of foetus, 332 

in puerperal insanity, 576 
Hermaphrodites, false, 324 

true, 324 
Hernia, including uterus, cause of dystocia, 
455 
inguinal, crural, cause of dystocia, 462 
navel-cord, 316 
of uterus, 455 

gravid, 736 
umbilical, in foetus, 492 
in newborn child, 638 
Herniee, external abdominal, 327 

inguinal or crural, obstructing labor, 462 
internal abdominal, 327 
varieties in maldevelopment, 327 
Herpes in pregnancy, 408 
Hind-gut, development of, 82 
Hirst, measurements of pelvis, 425 

pelvimeter, 224 
History of patient, case records, 224 
Holoblastic segmentation of ovum, 76 
Holt incubator, 296 
Hot-air bath, 544 

Hot-water in post-partum hemorrhage, 530 
Hot pack, 544 

Humerus, fracture of, at birth, 630 
Hydatids (cysts) of Morgagni, 50, 110 
Hydreemia in eclampsia, 538 
Hydramnios. 305 

differential diagnosis of, 306 
etiology and symptoms of, 305 
frequency of, 305 
in multiple pregnancy, 301 
in plural births, 493 
post-partum hemorrhage from, 527 
prognosis and treatment of. 307 
Hvdrencephalocele, 627 
Hydrocephalus, 488 

cause of dystocia, 488 
development of, 329 
in foetus, diagnosis of. 489 
relation of, to labor, 490 
treatment of, 490 



INDEX. 



771 



Hydromeningocele, 4SS 

cause of dystocia, 488 
Hydronephrosis, foetal, 338, 491 
Hydrorrhacis, 492 
Hydrorrhcea gravidarum, 304 

diagnosis from hydramnios, 306 
Hydrothorax. cause of dystocia, 491 

foetal, obstructing labor, 491 
Hymen, anatomy of, 22 

tears of, 250 

varieties of, 22. 23 
Hyosciu bydrobromate in puerperal insan- 
ity. 582 
Hyperemia, cerebral, in eclampsia, 538 
Hyperemesis gravidarum, 400 
Hyper! actation, 575 
Hysterectomy for inversion of uterus, 506 

indication for, 506 

in puerperal infection, 624 
Hysteria, contraindication to nursing, 274 

diagnosis from eclampsia, 540 

ICE in mastitis, 573 
in post-partum hemorrhage, 530 
Ichthyosis, foetal, 339 
Icterus neonatorum, 639 
grave form, 639 
mild form, 639 
"true," 639 
Idiocy from forceps operation, 681 
Immature labor. See Abortion. 

treatment of, 356 
Impregnation of ovum, site of, 75 
Incubation for premature children, 294 

period of, 297 
Incubators. 294 

temperature of, 294, 295 
Inertia uteri, 413 

indication for forceps in, 680 
in twin births, 493 
retention of placenta from, 672 
Infant mortality with prolapsus funis, 499 
new-born, cyanosis of, 628 
over-feeding of, 291 
premature, care of, 293 

feeding of, 297 
stools of, 292 
weight-chart of, 292 
weight of, at birth, 292 
Infarcts of placenta, 312 
Infection, auto-, 599 
intra-partum, 610 
maternal, from dead foetus, 334 
puerperal, 581, 583 

from gas bacillus, report of a case, 
567 
umbilical, 640 
Infectious diseases as cause of abortion, 342 

during pregnancy, 155 
Inferior strait, 162 
Infundibular pregnancy, 360 
Infusions, saline, after post-partum hemor- 
rhage, 532 
Insanity, puerperal, 576 
etiology of, 576 
forms and symptoms of, 557 
prodromal period of, 578 
prognosis and treatment of, 580 
Inspection of abdomen in diagnosis, 131 
Instruments for repair of vaginal lacera- 
tions, 654 
sterilization of, 228 
Insufflation, direct, in asphyxia, 634 



Intercourse, sexual, during pregnancy, 154 

Interstitial pregnancy, 360 

Intestinal fermentation in newborn child, 

646 
Intestine, development of, 106 
Intestines of newborn child, 270 
Intraspinal cocainization, 241 
Intravenous injection of salt solution in 

post-partum hemorrhage, 532 
Introitus vaginae, 21 
Inversion of uterus, complete, 501 
frequency, 501 
partial, 501 

prognosis and treatment of, 504 
Involution, in abortion, 349 

tardy, 264 
Iodoform -gauze tampon of uterus, 531 
Iris, development of, 100 
Iron in pre-eclamptic state, 544 

in puerperal insanity, 582 
Ischio-rectal fossa, anatomy of, 30 
Ischium, spine of, as an obstetric landmark, 
163 
tuberosities of, 163 
Islands of Pander, 88 

Isolation in treatment of puerperal insanity, 
581 

JACQTJEMIN sign in diagnosis, 139 
Jaundice, 641 
Jewett sign in diagnosis, 140 
Joints, pelvic, mobility of, 162 
sacro-coccygeal, 160 
sacroiliac, 160 
symphysis pubis, 161 

KAKYOKINESIS, 76 
Kidney, development of, 109 
Kidneys, diseases of, in foetus, 338 
in puerperal eclampsia, 537 
floating, cause of dystocia, 462 
horse-shoe formation, 323 
of newborn child, 270 
Kiestein, 125 
Knee-chest position in threatened abortion, 

352 
Knife of Farabeuf. 749 
of Galbiati, 749 

LABIA majora, anatomy of, 18 
development of, 113 
minora, anatomy of, 19 

changes produced in, 20 
development of, 113 
frsenulum of, 19 
prseputium of, 19 
Labium, abscess of, 460 

Labor, abdominal examination in, first 
stage, 235 
accidental, complications of. indicating 

forceps, 680 
anaesthesia in, 239 

anomalies of, arising from accidents or 
disease, 498 
mechanism, 409 
of the passages, 420 
cardiac disease an indication for induc- 
tion of, 563 
causes of onset of, 193 
cervical rings in, 199 
clinical phenomena of beginning. 195 
complicated by placenta pnvvia, 520 
definition of, 192 



772 



INDEX. 



Labor, delayed, 412 
causes of, 413 
diagnosis of, 414 
prognosis of, 415 
symptoms of, 413 
treatment of, 415 
diagnostic signs of beginning, 234 
difficult, anomalies of soft parts, 453 

pelvic deformities in, 420 
dilatation of cervix, mechanism of, 196 
duration of, 192 
effect of diabetes on, 562 
of eclampsia on, 537 
expelling powers, abdominal muscles, 
158 
contraction of uterus, 157 

strength, 158 
force of uterine contractions, 

158 
pelvic floor action, 159 
uterine changes in shape and 
position, 158 
face presentations, 465 
false or spurious, in ectopic gestation, 

380 
final duties of physician, 247 
first stage, bladder and rectum, 201 
emotional influences, 201 
management, 234 
pains, 200 

preparation of patient for, 239 
pulse, 201 
secretions, 201 
show, 200 

thinning of cervix, 201 
following operations for uterine dis- 
placements, 456 
general rules in management of, 237 
hemorrhages in, 516 
hydrostatic pressure in, 198 
immature, treatment of, 356 
in bicornate uterus, 453 
in compressed pelvis, 440 
induction of, in ansemia, 406 
in eclampsia, 547 
in hydramnios, 305 
in pre-eclamptic state, 544 
Krause's method, 520 
influence of contracted pelvis on, 428 
in kyphotic pelvis, 446 
in scoliotic pelvis, 449 
in twin births, 493 

irregularity of action of uterus in, 417 
management of, 211 
first stage in, 234 
in birth of trunk, 243 
in brow presentation, 470 
in face presentation, 468 
in multiple pregnancy, 302 
in occipito-posterior cases, 464 
in pelvic presentation, 473 
in placenta praevia, 520 
in plural births, 493 
in second stage, 237 
in transverse presentation, 484 
mechanical elements of, 157 
mechanism of, 192 
anomalies, 409 

of expellant forces, 411 
in brow presentation, 469 
in face presentation, 467 
in flat rachitic pelvis. 433 
in obliquely contracted pelvis, 438 



Labor, mechanism of, in occipito-posterior 
position, 462 
in pelvic presentation, 472 
main factors in, 409 
with large foetus, 487 
method of keeping history of, 227 
missed, 358 

fate of child in, 359 
treatment of, 358 
normal, 192 

definition of. 192 
duration of, 192 
nurse's preparation for, 233 
occiput-posterior cases, operative pro- 
cedures in, 464 
pains of, 200 
passages in, parts of pelvis, 160 

pelvis, bonv, obstetric anatomy of, 
159 
brim of, 162 
false, 162 
joints of, 160 

sacro-coccygeal, 160 
sacro-iliac, 160 
symphysis pubis, 161 
true, 162 
pathology of, 409 

perineal stage, management of, 241 
physiology of, 157 
positions during, 237 
precipitate, 411 
causes of, 411 
post-partum hemorrhage following, 

527 
sequelae of, 412 
treatment of, 412 
prediction of date of, 150 
premature, 358 
causes of, 359 
definition of, 340, 661 
induction of, 661 

in obliquelv contracted pelvis, 
438 
in multiple pregnancy, 302 
methods of inducing, 670 
operation of induction of, 670 
treatment of, 359 
prematurity of, in plural births, 496 
preparation for, 233 
of bed for, 234 
of patient for, 232 
of room for, 233 
preparatory treatment for, 211 
probable date of, 149 
prognosis, in normal, 236 
prolonged, central paralysis from, 632 
record of, 225 

retraction of pelvic floor in, 200 
second stage of, 206 

clinical phenomena of, 206 
delivery of trunk in. 206 
descent in, mechanism of, 201 
examination during, 237 
extension in, mechanism of, 204 
external rotation in, mechanism of, 

206 
flexion in, mechanism of, 203 
management of, 237 
moulding of head in, 207 
restitution in, mechanism of, 206 
rotation in, mechanism of, 203 
spasm of uterus in, 417 
causes of, 417 



IXDEX. 



773 



Labor, spasm of uterus in, diagnosis of, 417 
prognosis of, 418 
Treatment of, 418 
spurious, changes after, 380 
in ectopic gestation, 380 
stages of. 192 

third stage of, clinical phenomena of, 
•209 
management of, 244 
uterine retraction in, 196 
vaginal examination in first stage, 235 
walking about in first stage, 236 
with contracted pelvis, 420 

treatment of, 429 
with foetal monstrosity, 497 
with "funnel-shaped" pelvis, 430 
with justo-major pelvis. 427 
with justo-minor pelvis, 428 
with pelvic anomalies, 430 
with spondylolisthetic pelvis, 444 
Laceration of perineum, immediate suture 
of, to prevent infection, 619 
repair of, 652 
vaginal, 649 

complete, 656 
immediate repair of, 649 
walls, 251 
vulvar, 649 

complete, 656 
immediate repair of, 649 
superficial external, 651 
Lactation, 257 

during puerperium, 257 
length of period of, 258 
termination of, 263 
Lactose in urine, 125 

during pregnancy, 562 
Lanugo, disappearance of, 116 
Larynx, development of, 107 
Laxatives for use in pregnancy, 154 
Lead-poisoning a cause of abortion, 342 
Lecithin in milk, 280 
Lemon juice in post-partum hemorrhage, 

531 
Levator ani, action of, 649 
Ligament, ano-coccygeal, 32 
broad, development of, 111 

(mesosalpinx), anatomy of, 46 
greater sacro-sciatic, 163 
infundibulo-pelvicum, 46 
interosseous, 160 
lesser sacro-sciatic, 163 
of bladder, 37 
of Cooper, 66 
of ovaries, 53 
of pelvis, 160 
of uterus, 62 
pubic, 161 

round, of uterus, 53 
rigidity of, 134 
sacro-iliac, 160 
sacro-sciatic, greater, 163 
lesser, 163 

relation to pelvic outlet, 163 
suspensorium ovarii, 46 
triangular, 34 

anatomy of, 37 
uterine, anatomy of, 53, 62 
utero-sacral, 30- 
Ligamentum arcuatum 161 
Limbs, foetal, prolapse of, 486 
Linese albicantes, 132, 151 
Liquor amnii, 201 



Liquor amnii, composition and function of, 
84 

folliculi, 72 

secretion of, 84 
Lithopedion, 381 
Liver, abnormal location of, 331 

circulation of, in embryo, 94 

development of, 106 

diseases of, in foetus, 338 

during pregnancy, 123 

of new-born child, 270 

tumors of, obstructing labor, 462 
Local causes of abortion, 343 

conditions to be treated in puerperal 
insanity, 581 
Location of anterior shoulder, 216 

of cephalic prominence, 217 

of foetal back and small parts, 213 
heart, 218 
Lochia, 254 

alba, 254 

amount of, 254 

bacteriological examination of a series 
of cases, 590 

effect of stoppage of, 577 

in abortion, 349 

in puerperal infection, 607 

rubra, 254 

serosa, 254 

stoppage of, in puerperal insanity, 577 
Lohlein, measurement of pelvis, 425 
Lordosis deforming pelvis, 449 
Lubricants, 232 
Lungs, development of, 107 

diseases of, in foetus, 337 

of new-born child, 268 
Lying-in chamber, during puerperium, 261 

preparation of, 233 
Lymphangitis, puerperal, 594 
Lymphatics, diseases of, in foetus, 337 

of mammary gland, 70 

of newborn child, 271 

of pelvic floor, 54 

of pudendum, 20 

MACEEATION of foetus, 334 
Magnesium sulphate to induce abor- 
tion, 664 
Major operations as cause of abortion, 343 
Malacia in pregnancy, 405 
Malarial fever simulating puerperal infec- 
tion, 612 
Malnutrition in foetus, 334 
Malpighian bodies, development of, 109 
Malpighii, bodies of, 109 
Malpositions in placenta prrevia, 519 
in twin births, 493 
with prolapsus funis, 498 
Malpresentation in placenta prarvia, 519 

with prolapsus funis, 498 
Malrotation of head in breech cases. 480 
Mammary glands, accessory glands of, 66 
anatomy of, 64 
changes of, in pregnancy. 65 
hygiene of, during pregnancy, 153 
lobes of, 65 
lymphatics of, 70 
nerves of, 70 

signs of pregnancy in, 128 
vessels of, 68 
infection, source of, 571 
signs of pregnancy. See Pregnancy, 
diagnosis of. 



774 



IJSDEX. 



Management of labor, 234 
Manual dilatation in eclampsia, 552 
in placenta prsevia, 522 
extraction in pelvic presentations, 478 
Massage in birth paralyses, 632 

mammary, 572 
Mastitis, 570 

etiology of, 570 

forms of, 572 

in new-born child, 638 

treatment of, 638 
prophylactic treatment of, 572 
symptoms of, 571 
treatment of, 572 
suppuration in, 573 
Masturbation, changes in breast from, 130 
Mauriceau method of manual extraction, 478 
Maxilla, inferior, development of, 104 

fracture of, at birth, 630 
Maxillary process, 104 
McLean's bag in placenta preevia, 522 
Meatus urinarius, anatomy of, 21 
Meconium, 292 

in diagnosis of breech cases, 471 
Medulla oblongata, development of, 98 
Medullary groove, 80 

plate, 80 
Melancholia, puerperal, 578 
Membrana granulosa of Graafian follicle, 53 
Membrane, pseudo-diphtheritic, in puerperal 

vaginitis, 592 
Membranes, adhesion of, 208 
caution in delivery of, 672 
conditions of, for application of forceps, 

679 
detachment of, 208 
early rupture of, 198 
examination of, 245 

in premature labor, 671 
in face presentations, 468 
in multiple pregnancy, 300 
premature rupture of, a cause of pro- 
lapsus funis, 498 
rupture of, 201, 238 
during labor, 238 
in accidental hemorrhage, 526 
in partial detachment of placenta, 

520 
in uterine inertia, 416 
separation of, in induction of labor, 671 
uterine development of, 82 
with twins, 300 
Meningeal apoplexy in newborn child, 632 
Meningitis, diagnosis from eclampsia, 541 
Meningocele, 627 
Menstrua] discharge, 71 

Menstruation, apparent, during pregnancy, 
127 
causes of, 71 

character of discharge, 71 
coincident with ovulation, 73 
disturbances of, in ectopic gestation, 371 
duration of, 71 
in pregnancy, 126 
normal, 71 
occurrence of. 71 
physiology of, 71 
return of, after labor, 249 
suppression of, diagnostic value, 126 
Mental affections in pregnancy, 407 

coudition, care of, during puerperium, 
261 
during pregnancy, 155 



Mental impressions a cause of onset of labor, 
195 
rest in puerperium, 260 
Mercurial ointment in congenital syphilis, 

644 
Mercuric chloride as an antiseptic, 229 

iodide as an antiseptic, 229 
Mesenchyme, 79 
Mesentery, development of, 106 
Mesoderm, development of, 78 
of ovum, 78 

tissues developed from, 80 
Mesogastrium, 105 
Mesorectum, 32 
Mesothelium, 79 
Metritis, chronic, 146 

puerperal, 595 
Metrorrhagia, a contraindication to nurs- 
ing, 274 
Milk and cream mixtures, 284 

changes in, from sterilization, 287 
condensed, 288 
cows', dilution of, 281 
modifying of, 281 
removal of casein from, 282 
effect of excess of fat in, 289 

of sugar in, 289 
"fever," 610 

no such thing, 256 
Gartner's, 286 
human, abnormal, 276 

chemical composition of, 258 
composition of, 274 

at different months, 277 
daily secretions, 276 
normal, 275 
table of variation, 276 
variations in quantity and compo- 
sition, 276 
vs. cows', 279 
hypersecretion of, 572 
laboratories, 288 
maternal, 274 

presence of bacteria in, 571 
mechanical modification of, 286 
microscopical examination of, 275 
modified, 281, 282 

Eotch, 284 
Pasteurization of, 2S7 
peptonization of, 284 
preparation of, Vigier's method, 284 
secretion of, in pregnancy, 130 
stasis, 570 
sterilized, 286 

advantages of, 287 
Miscarriage (immature labor), 340 

definition of, 340 
Mitral valve, lesions of, 563 
Mole, blood, 346 
fleshy, 346 
tubal, 369 
vesicular, 309 
Monro, foramen of, 97 
Mons pubis. See Mons veneris. 
Mons veneris, anatomy of, 17 
Monsters, double, obstructing labor, 497 
foetal, diagnosis of, 467 
relation of, to labor, 497 
Monstrosities in multiple pregnancy, 301 

obstructing labor. 496 
Montgomery, follicles of, 130 

glands of, 65 
Monti modification of milk, 285 



INDEX. 



775 



Morbus caeruleus, causes of, 96 
Morgagni, cysts of, 50 
Mortality in eclampsia. 543 

maternal, in concealed " accidental hem- 
orrhage," 524 
in placenta praevia, 519 
in podalic version for placenta 

pnevia, 523 
in rupture of uterus, 511 
Morula of ovum, 77 
Mother, examination of, after labor, 246 

dangers to, from version, 714 
Moulding of foetal head, 207 

excessive, 629 
Month, development of, 103 
Miiller, ducts of, 44 
Mummification of foetus, 334 
Murphy binder, 572 

Muscles, abdominal, action of, in labor, 158 
coccygeus, 40 

compressor urethras, anatomy of, 44 
constrictor vaginse, anatomy of, 34 
corrugator cutis aui, 30 
erector clitoridis, anatomy of, 34 
Guthrie's, 44 

injuries to, in newborn child, 530 
internal sphincter ani, anatomy of, 31 
ischio-bulbosus, 34 
ischio-cavernosus, 34 
levator ani, anatomy of, 37 
obturator internus, anatomy of, 35 

relation to parturient canal, 173 
plates, development of, 81 
pyrif oralis, anatomy of, 35 

relation to parturient canal, 173 
sphincter aui externus, anatomy of, 32 
interims, anatomy of, 31 
vaginas, anatomy of, 21, 34 
transversus perinei, anatomy of, 34 
Muscular system, diseases of, in foetus, 338 
Myoniata, uterine, with prolapsus funis, 498 
Myotomes, development of, 81 

NABOTHIAX follicles, 61 
Naegele's rule, 150 
Naevi, 337 

Naphthalin internally, indication for, 582 
Nasal passages, development of, 105 
pits, 105 
process, 105 
Nausea and vomiting, diagnostic value of, 
127 
during pregnancy, 399 
Navel, protrusion of, 131 
Neck-bend of embryonic brain, 96 
Nephritis, acute, an indication for induction 

of abortion, 662 
Nerves of Fallopian tubes, 57 
of mammary gland, 70 
of ovaries, 57 
of pelvic floor, 54 
of pudendum, 54 
of uterus, 57 
of vagina, 55 
Nervous system, brain, neck-bend, 96 
primary head-bend, 96 
Yarolian bend, 96 
central, development of, 96 
changes in, during pregnancy, 125 
diseases of, contraindication to 

nursing, 274 
disorders of, in pregnancy, 407 
fore -brain, 96 



Nervous system, hind-brain, 96 

mid-brain, 96 
Neural canal, 80 

of newborn child, 267 
organs of special sense, 99 
primary cerebral vesicles, 96 
spinal cord, 98 
Neuralgia in pregnancy, 408 
Nipple, anatomy of, 65 
erectility of, 130 

shields, use of, with sore nipples, 569 
Nipples, anomalies and diseases of, 567 
treatment of, 569 
care of, 212 

during pregnancy, 153, 568 
infection from, 570 
irritation of, to stimulate uterine con- 
traction, 663 
sore, 568 

etiology of, 568 
treatment of, 568 
curative, 569 
preventive, 568 
Nitrate of silver in fissured nipples, 569 

in ophthalmia, 642 
Nose, development of, 105 
Notochord, 81 

Nourishment during puerperium, 259 
Nuclein in milk, 280 

in treatment of puerperal infection, 626 
Nucleolus of ovum, 74 
Nucleus of ovum, 74 

segmentation of, 76 
Nurse, antiseptic precautions for, 232 
Nursing-bottles, 290 
Nursing, hygiene of, 262 
maternal, 273 

contraindications to, 274 
of infant, contraindications to, 262 

time of, 273 
of newborn child, 273 
painful, relief of, 569 
to stimulate uterine contractions, 262 
weaning child, 263 
wet-, 278 
Nutrition, maternal, changes due to preg- 
nancy, 124 
weight as a sign of, 291 
Nymphse. See Labia minora. 

OATMEAL-water in diluting milk, 281 
Obesity vs. pregnancy, 146 
Obstetric examination, objects of, 155 

surgery, 649 
Obstetrician, armamentarium of, 227 

duties of, during labor, 211 
Obturator foramen, 163 
Occipital protuberance, 177 
Occiput, 177 

Occiput-posterior cases, abnormal forms, 463 
diagnosis of, 462 
mechanism of labor, 462 
QMema during pregnancy, 123 

foetal, 338 

general, of foetus obstructing labor, 491 

in hydramnios, 305 

of vulva, cause of dystocia, 459 

suprapubic, in plural pregnancy, 302 
(Esophagus, development of, 105 
Oidinm albicans, 644 
Olfactory plates, 105 
Oligo-hydramnios, 304 

in plural births, 493 



776 



INDEX. 



Oligohydramnios, relation of, to talipes, 338 
Omentum, development of, 106 
Omphalo-mesenteric vessels, 91 
Omphalocele, 316 
Oophoritis, puerperal, 595 
Operating gown, 682 

suit, 232 
Operation for immediate repair of internal 
vaginal lacerations, 653 
of lacerated cervix, 660 
Operations, episiotoiny, 243 

for perineal operations, 653 
Operative interference in delayed labor, 417 
Ophthalmia neonatorum, 641 

treatment of, 642 
Opisthotonos in eclampsia, 536 
Opium in abortion, 351 

in " accidental hemorrhage," 525 

in delayed lahor, 415 

in eclampsia, 546 

in threatened abortion, 351 

in uterine inertia, 415 
Optic cup, primary, 99 
secondary, 100 

nerves, development of, 97 

vesicles, development of, 97 
Oral plate, 103 

Organic diseases as cause of abortion, 342 
Organs, abdominal, enlargement of, re- 
sembling pregnancy, 147 

of Eosenmiiller. See Parovarium, 
development of, 111 

of special sense, development of, 99 
Osseous system, changes in, due to preg- 
nancy, 124 
diseases of, in foetus, 338 
Osteophytes, puerperal, 124 
Ostium vaginae, 21 
Otocyst. See Auditory vesicle, 102 
Outlet, pelvic, diameters of, 168 
landmarks of, 163 
plane of, 165 
Ovarian cystoma, diagnosis from hydram- 
nios, 306 

pregnancy, 360 
Ovaries, anatomy of, 50 

nerves of, 57 

vessels of, 57 
Ovary, cortical zone of, 52 

cystoma vs. pregnancy, 147 

development of, 110 

tumors of, cause of dystocia, 461 

tunica albuginea of, 52 

zona vasculosa of, 52 
Oviducts. See Fallopian tubes. 
Ovula of Naboth, 61 
Ovulation, physiology of, 72 
Ovum, changes in, in ectopic gestation, 365 

development of, 73 

fertilization of, 73, 75 

loosening attachment of, in labor, 194 

maturation of, 73, 74 

nourishment of, 83 

zona pellucida of, 74 
radiata of, 74 
Oxygen in eclampsia, 553 

inhalations in pre-eclamptic state, 544 
Ozsena a source of infection in puerperium, 
597 

PAD, perineal, 653 
Pain in ectopic gestation, 380 
Pains, after-, 209, 254, 261 



Pains in uterine inertia, 413 
rupture, 509 
labor-, 200 

weakness of, 412 
Pallor in insanity, 579 
Palpation of anterior shoulder, 216 
of cephalic prominence, 217 
of fcetal parts in abdominal examina- 
tion, 132 
of lower fcetal pole, 214 
of upper foetal pole, 216 
Palpitation during pregnancy, 123, 405 

from heart lesions, 564 
Pampiniform plexus, 57 
Pancreas, development of, 107 
Pander, islands of, 88 
Paralysis, central, in newborn child, 632 
Duchenne's, diagnosis of, 631 

in newborn child, 631 
Erb's, 631 

facial, in newborn child, 630 
Parametritis, puerperal, 595 
Parietal protuberance, 177 
Paroophoron, anatomy of, 53 
Parovarium, 111 
anatomy of, 53 
development of, 111 
Pars intermedialis, 26 
Parsley, ecbolic action of, 663 
Passages, maternal, obstructions of, indicat- 
ing use of forceps, 680 
Pathology of foetus, 317 

of pregnancy, 299 
Patient, disinfection of, preparatory to- 
labor, 613 
Pelvic deformities, classification of, 426 
fascia, anatomy of, 35 
floor, action of, in labor, 159, 
anatomy of, 32 

blood- and nerve-supply of, 54 
changes in, due to pregnancy, 122 
fasciae of, 649 
measurements of, 173 
muscles of, 32-34 
retraction of, in labor, 200 
segments of, 173 
structure of. 173 
organs, care of, during pregnancy, 154 
female, anatomy of, 17-70 
hygiene of, during pregnancy, 154 
peritoneum, changes due to pregnancy, 

121 
presentation, a cause of dystocia, 470 
diagnosis of, 471 
etiology of, 470 
frequency of, 470 
general management of, 473 
malrotation of head, 480 
management of special conditions 
in, constriction of 
head by uterus, 477 
impaction of breech, 475 

of head, 478 
non-engagement at 

brim, 474 
upward displacement 
of arms, 476 
' mechanism of, 472 

abnormalities of, 473 
methods of delivery, after embrylu- 
cia, 479 
forceps extraction, 478 
manual extraction, 478 



INDEX. 



777 



Pelvic deformities, prognosis of, 472 
Pelvimeter, COS 

Baudelocque's, 423 
Collyer's, 220 
Hirst's, -2-24 
Pelvimetry, 422 
external, 223 
internal, 222, 424 
in pelvic deformities, 422 
prognosis of, 472 
Pelvis. See Labor. 

anchylosis of joints of, 446 

anomalies of size, shape, or inclination, 

429 
antero-posterior diameters of, 422 
articulations of, during pregnancy, 122 
bony, development of, 113 
brim of, 162 

plane of, 165 
cavity of, true, 163 
changes due to pregnancy, 122 
compressed (malacosteon), 440 
diagnosis of, 440 
etiology of. 440 
influence of, on labor, 441 
pseudo-malacosteon, 441 
treatment of, 441 
constituent parts of, 160 
contracted, forceps in, 680 

obliquely (Xaegele pelvis), 437 
etiology and diagnosis of, 438 
from imperfect use of one limb, 

438 
from lateral curvature of spine. 
439 
transversely (Robert pelvis), 439 
from kyphosis of spine, 440 
deep, 430 
deformities of, 420 

eequabiliter-justo-rnajor, 427 

justo-minor, 427 
causes of, in early life, 422 
classification of, 426 
diagnosis of, 422 
distorted by anchylosis of, 446 

by double dislocation backward 

of femora, 444 
by fracture of pelvis, 446 
by injuries, disease, or tumors, 

444 
by tumors, 444 
due to spinal curvature, 446 
dwarf form, 427 

flat, non-rachitic, etiology and diag- 
nosis of, 430 
rachitic, 431 

breech delivery in, 434 
diagnosis of, 433 
etiology of, 432 
treatment of, 435 
simple, 430 
frequency of, 421 
from osteomalacia, 422 
from rachitis, 422 
from tuberculosis, 422 
funnel-shaped, 430 
infantile, 427 

in relation to post-part um state, 450 
justo-minor, etiology of, 427 

treatment of labor in, 429 
kyphoscoliotic, 449 
kyphotic, 446 

diagnosis of, 447 



Pelvis, deformities of, lordosis of, 449 
masculine, 429 
most-frequent varieties, 421 
Naegele, 431, 437 
obliquely contracted, 436 

imperfect development of 
one sacral ala, 
437 
diagnosis of, 483 
etiology of, 438 
influence on la- 
bor, 438 
treatment of, 438 
use of one limb, 438 
lateral curvature of spine 
in, 439 
pseudo-malacosteon, 433 
pseudo-rachitic, 441 
rachitic, generally contracted, 433 
infantile, 433 
rostrate, 433 

treatment of labor in, 435 
Robert, 439 
scoliotic, 448 
shallow, 429 
split, 446 
spondylolisthetic, 442 

etiology and diagnosis of, 143 
transversely contracted imperfect 
development of both sacral 
ala, 439 
kyphosis, 440 
uniformly contracted, 427 
enlarged, 427 
diameter of, diagonal conjugate, 424 
transverse, 167, 424 
true conjugate, 167 
doubly obliquely contracted, 439 
dwarf, 427 
dynamic, 169 

measurements, external, 169 
internal, 169 
examination of, in pregnancy, 168 
external circumference of, 170 

diameters of, in deformities, antero- 
posterior, 422 
in deformity, transverse, 424 
measurements of, in deformed pel- 
ves, 422 
in deformities, oblique, 424 
false, 162 
fractures of, 446 
Hirst's measurement of, 425 
inclination of, 166 
inferior strait. See Outlet, 
inlet. See Brim, 
internal diameters of, 167 

measurements of, 168, 424 
diagonal conjugate, 424 
isthmus. See Brim, 
landmarks at brim, 162 

at outlet, 163 
Lohlein's measurement of, 425 
male vs. female, 171 
measurements of, 170 
of Hirst, 425 
of Lohlein, 425 
middle plane of, 165 
minor developmental peculiarities of, 

429 
muscles of, 173 
oblique diameters of, 424 
obstetric anatomy of, 159 



778 



INDEX. 



Pelvis, obstetric planes of, 164 
outlet of, 162 

plane of, 165 
parturient axis of, 174 
racial differences in, 172 
shape of pelvic canal, 168 
small, in puerperal eclampsia, 540 
soft parts of, 172 
static measurements, brim, 167 
middle plane, 168 
outlet, 168 
true, 162 

cavity of, 163 
margin of, 162 
Penis, development of, 113 
Pennyroyal, ecbolic action of, 663 
Perchloride of iron not to be used in post- 
partum hemorrhage, 531 
Perforation, indications for, 723 
Pericardial effusion, fcetal, 491 
Perineal body, anatomy of, 41 
ledge, anatomy of. 34 
space, anatomy of, 34 
boundaries of, 17 
Perineum, anatomy of, IS 

effect of extensive rupture of, 577 
immediate repair of, 658 
lacerations of, 656 

in precipitate labor, 412 
prevention of, 241 
Peritoneum covering the ovary, 52 

pelvic, 121 
Peritonitis, 609 

in ectopic gestation, 380 
puerperal 596 
Perivitelline space, 74 

Permanganate method of disinfection, 231 
Peroxide of hvdrogen as an antiseptic, 

230 
Pniiger, cords of, 111 
Phantom tumor vs. pregnancy, 148 
Pharynx, development of, 104 
Phlebitis, puerperal, 593 
Phlegmasia alba dolens, 596 

in puerperal infection, 610 
Physiology of ovulation, 72 

of pregnancy, 71-156 
Physometra, 359 
Pica of pregnancy, 405 
Pigmentation in pregnancy, 128, 132 
of abdomen in pregnancy, 134 
of breasts, 128 

of nipples and abdomen, 257 
Pilocarpine in eclampsia, 551 

in inducing labor, 663 
Pinard's rule, 487 
Placenta, accessory, 311 
adherent, 671 

causes of. 672 
treatment of, 673 
after abortion. 348 
anomalies of, 311 
of position, 311 
of shape. 311 
of size, 311 
battledore, 311 

calcareous degeneration of, 314 
causes of retention of, 672 
changes of, in tubal pregnancy, 369 
circumvallata. 311 
complete separation of, in placenta prEe- 

via. 523 
cotyledons of, 86 



Placenta, Crede's method of expulsion of, 
244 
cysts of, 314 
detachment of, 208 

in placenta prsevia, 524 
diseases of, 312 
examination of, 245 

in premature labor, 671 
expression of, 244 
expulsion of, in labor, 208 

in twin birth, 302 
fatty degeneration of, 314 
horseshoe shape, 517 
infarcts of, diagnosis and treatment of, 
313 

effects of, on foetus, 313 

etiology of, 313 

frequency and pathology of, 312 
in multiple pregnancy, 300 
layers of, 86 
location of, 220 

from external signs, 134 
marginata, 311 
membranacea, 311 
nietbod of expulsion of, 208, 618 
partial separation of, in placenta prse- 

via, 523 
position of, 311 
prsevia, 516 

as cause of abortion, 344 

diagnosis of, 518 

etiology and symptoms of, 517 

examination of, by vagina, 518 

frequency of, 516 

hemorrhage from, etiology of, 517 

instruments used in cases of, 521 

post-partum hemorrhage from, 528 

rupture of membranes in partial 
detachment of, 520 

structural anomalies of, 517 

symptoms of, 517 

treatment of, 519 

after the foetus is viable, 519 
before the seventh month, 519 

varieties of, 516 
primitive blood-vessels of, 88 
retained, 671 

causes of, 672 

secondary hemorrhage from, 533 

treatment of, 672 
shape of, 311 
size of, 311 
spuria, 311 
structure of, 86 
succenturiata, 310, 311 
syphilis of, 314 

treatment of, in Csesarean section, 
739 

in rupture of uterus, 512 
tumors of, 314 
white infarctions of, 312 
with twins, 300 
Placentae in triplet births, 496 
spuria?, 314 

succenturiatee, 300, 311 
Placental apoplexy, 312 

symptoms and treatment of. 313 
separation, mechanism of, 671 
Placentitis. 314 

adherent placenta from, 672 
Planes of foetal head. 179 
of pelvis, brim. 165 

middle, 165 



IXDEX. 



779 



Plaues of pelvis, outlet, 165 
Pleura, development of, 107 
Pleural sacs, development of, 107 
Plexuses, nerve, inferior hypogastric, 57 
ovarian, 57 
venous, of ovaries, 57 
of vagina, 55 
pampiniform. 57 
Plica trausversalis recti, 31 
Plural births, cause of dystocia, 493 
Pneuinococeus in puerperal infection, 587 
Pneumonia, foetal. 337 
Polar globule. 75 
Polygalactia, 575 
Polyhydramnios, 305 
Polypi, decidual, 346 

uterine, secondary hemorrhage from, 
531 
Polypus of uterus, cause of dystocia, 458 
diagnosis from inversion, 504 
placental, after abortion, 346 
Pons Varolii, development of, 97 
Porro-Csesarean operation, 743 
advantages of, 743 
for carcinoma of cervix with preg- 
nancy, 158 
indications for, 743 
in malacosteon pelvis, 441 
technique of, 743 
section, indications for, 743 
technique of operation, 743 
Position of child, definition of, 181 

determination of, from fcetal heart- 
sounds, 137 
diagnosis of, 213 

mento-anterior, indication for for- 
ceps in, 6S0 
occipito-posterior, indication for for- 
ceps in, 680 
relative frequency of, 182 
varieties of, 182 
of presenting part, determination of, 
181, 182 
Posterior commissure, 18 
Post-partum hemorrhage, secondary, causes 

and treatment of, 533 
Posture, definition of, 191 
for prolapse of cord, 500 
obstetric, during labor, 237 
of foetus, 191 

of patient in forceps operation, 683 
Pouch, vesico-uterine, 43 
Preeputium, anatomy of, 19 
Prague grasp in pelvic presentation, 478 
Pre-eclamptic state, 535 

treatment of, 543 
Pregnancy, abdominal, 360 
signs of, 131 
without rupture, 376 
affected with justo-major pelvis, 427 
changes in maternal organs caused by, 

117 
cornual. 360, 392 
diagnosis of, 126 

abdominal signs of, 131 

auscultation, 134 
heart, foetal, 134 

maternal, 134 
murmur, umbilical, 137 

uterine, 137 
shock, foetal, 138 
inspection, contour, 131 
pigmentation, 132 



Pregnancy, diagnosis of, abdominal signs of, 
inspection, striation, 
132 
value of, 132 
palpation, 92 

ballottement, 133 
contractions, 133 
fcetal movements, 133 

parts, 132 
size of fundus, 132 
summary of, 1 31 
history of, 126 
mammary signs in, 128 

breast enlargement, 128 
milk secretion, 130 
pigmentation, 128 
primary areola, 128 
secondary areola, 130 
summary of, 128 
value of, 130 
veins of, 128 
nausea and vomiting, 127 
order of examination, 131 
preparation for examination, 131 
pelvic signs, early change in uterus, 
140 
intermittent contractions, 

141 
method of examination of, 

138 
purplish hue of cervix, 139 
of vagina, 139 
quickening in, 128 
salivation in, 128 
signs by months in, 145 
suppression of menses in, 126 
differential, in early months, 146 

in later months, 146 
diseases of, 394 

albuminuria, 398 
causes of, 398 
diagnosis of, 399 
treatment of, 399 
toxaemia, 394 

etiology of, 394 
nature of poisons in, 395 
prophylaxis of, 396 
symptoms and diagnosis of, 395 
treatment of, 397 
disorders of, anaemia, 406 
dental caries, 405 
dyspnoea, 407 
herpes, 408 
mental affections, 407 
nausea and vomiting, 399 
symptoms of, 399 
treatment of, 402 
neuralgia, 408 
palpitation, 405 
pica or malacia, 405 
ptyalism, 404, 405 
syncope, 406 
duration of, 149 
early abortion in, 341 
evidence of previous. 151 
extra-uterine. See Ectopic gestation, 
general changes during, 122 
hygiene of, 152 
bathing, 153 
clothing. 153 
coitus, 154 
diet, 152 
digestive organs, 152 



780 



INDEX. 



Pregnancy, hygiene of, drugs, 155 

examination during, 155 

exercise, 153 

infectious diseases, 155 

mammary glands, 153 

mental condition, 155 

pelvic organs, 154 

rest, 153 

urine, 154 
infundibular, 360 
in patients not menstruating; 127 
interstitial, 360 
management of, 152 
multiple, 299 

diagnosis of, 301 

frequency of, 299 

management of labor in, 302 

mode of origin of, 299 

pathology of, 301 

post-partum hemorrhage from, 527 

sex of twins, 300 
ovarian, 360 
pathology of, 299 
pelvic signs of, 138 
physiology of, 71-156 
plural, heart-sounds in, 137 
post-mortem evidences of recent, 151 
previous, evidence of, 151 
recent, signs of, 265 
signs of. tabulated by months, 145 
spurious, diagnosis of, 148 
tubal, 360 

rupture of, diagnosis from acci- 
dental hemorrhage, 525 

unruptured. 376 
twin, diagnosis from hydramnios, 306 
value of mammary signs in, 130 
Premature infants, care of, 293 

labor, definition of, 340 
Preparations for labor, 232 
Presentation, breech, prolapse of limbs in, 
486 
brow, 469 
definition of, 181 

determination of, from foetal heart- 
sounds, 137 
diagnosis of, 213 
face, diagnosis and prognosis of, 466 

etiology of, 465 
head, prolapse of limbs in, 486 
longitudinal, 181 

pelvic, abnormalities in mechanism of, 
473 

diagnosis of, 471 

frequency of, 470 

management of special conditions 
in, 474 
relative frequency of, 181 
transverse, 181, 480 

decapitation in, 731 

diagnosis of, 481 

podalic version in. 701 

positions in, 481 

prolapse of limbs in, 486 

spontaneous delivery in, 482 

varieties of, 480 

version in, 711 
varieties of, 181 
vertex, recognition of. 236 
Presentations in twin births. 493 

relative frequency of different, 181 
Presenting part, 181 
Primipara, eclampsia in, 540 



Primitive streak, 80 
Processus globulari, 105 
Prochownick, diet to prevent dystocia, 452 
Prolapse of limbs, 486 

Prolapsus funis, diagnosis and prognosis of,. 
499 
frequency and etiology of, 498 
indication for use of forceps iu, 680 
treatment of, 500 
uteri, 456 
Pronucleus, female, of ovum, 75 

male, of ovum, 76 
Protargol in ophthalmia, 642 
Protuberances of foetal skull, 177 
Pseudo-hermaphrodites, female type, 325 

male type, 324 
Psychical disorders from forceps operation, 
681 
influence in puerperal insanity 576 
Ptyalism in pregnancy, 404 
Pudendum, anatomy of, 17 

vessels and nerves of, 20 
Puerperal fever, epidemics of, 596 
infection, 583 

air a source of, 598 
auto-infection in, 599 
bacteriology of, 584 
curative treatment of, 619 
diagnosis of, 610 
etiology of, 596 
external modes of, 598 
frequency of, 605 
modes of external, 598 
mortality from, 606 
organisms causing, 583 
pathological anatomy of, 590 
symptomatology of, 607 
treatment of, 615 
insanity, prognosis of, 580 
symptoms of, 577 
treatment of, 580 
state, definition of, 249 
sweats, 257 
ulcer, 591 
vaginitis, 591 
woman, care of, 259 
Puerperium, after-pains of, 254 
bowels in, 255 
care of genitalia in, 261 

of patient in, 259 
condition of outlet and vagina, 250 
danger of infection in, 250 
diagnosis of, 266 
final examination, 265 
lactation, 257 
pathology of, 567 
physiology of, 249 
pulse iu, 256 
temperature in, 255 
urine in, 255 

uterine involution in, 251 
visits of physicians, 264 
Pulmonary congestion in pregnancy from 
cardiac disease, 564 
organs, development of, 107 
Pulse after labor, 256 
chart, 226 

during puerperium, 256 
foetal, during labor, 201 
in acute an semi a, 518 
maternal, in labor, 201 
with post-partum hemorrhage, 528 
Purgation to induce abortion, 664 



IXDEX. 



781 



Purkiuje. vesicle of, 74 

Putrefaction, intestinal absorption of prod- 
ucts of, as a cause of puerperal in- 
sanity. 577 
of foetus, 334 
Pyseinia. 596 

symptoms of, in puerperal infection, 609 
Pyosalpiux, 60S 
Pyrosis in pregnancy, 394 

QUICKEXING, appearance of, 115 
diagnostic value of, 128 
reckoning date of labor from, 150 
Quinine, as cause of abortion, 343 
ecbolic action of, 663 
in abortion. 663 
in delayed labor, 416 

RECESSUS labyrintbi. 102 
Eecord. obstetric case-, 224 
Eectal injections of salt solution, 532 
Eecto- vaginal pouch, 32 
Eecto-vesical pouch, anatomy of, 30 
Eectum, ampulla of, 31 
anatomy of, 30, 173 
carcinoma of, cause of dystocia, 460 

secondary hemorrhage from, 534 
congenital malformations of, 629 
distention of, obstructing labor, 460 
impacted, a cause of retained placenta, 

672 
malformation of, in newborn child, 629 
relation of, to parturient canal, 173 
structure of. 30 
Respiration, artificial, in asphyxia of new- 
born child, 634 
Byrd's method, 635 
Laborde's method, 636 
Schultze's method, 635 
changes in, during pregnancy, 123 
disorders of, in pregnancy, 407 
following labor, 257 
in early infancy, 263 
of newborn child, 271 
Respiratory organs, maternal, changes due 

to pregnancy, 123 
Rest during pregnancy, 153 
Restitution of foetal head, 206 
Retina, development of, 100 
Retraction of uterus, 245 
Retroflexion of uterus resembling pregnancy, 

146 
Rheumatism, chronic, contraindication to 

nursing, 274 
Rickets, effect of, on pelvis, 432 

pelvic deformities associated with, 422 
Ring of Bandl, 197 
Rings, cervical, 199 
Room, lying-in, 261 
Rosenrnuller, organ of, 111 
Rotation, complete, in transverse presenta- 
tion, 482 
external, of foetal head, 206 
of head in labor, 203 
Rotch. cream mixtures, 284 

infant feeding, 288 
Round ligament, anatomy of, 18, 53 
Rowbotham, diet to prevent dystocia, 452 
Rue, ecbolic action of, 663 
Rupture of uterus, 506 

SACCHAROMYCES albicans, 644 
Sacculus, development of, 102 



Sacrum, promontory of, 162 
Saline infusion, in eclampsia, 551 

in puerperal infection, 623 
Salivation, diagnostic value of, 128 
Salpingitis, puerperal, 595 
Salt solution, 532 

use of, in eclampsia, 589 
Saprsemia, a cause of puerperal insanity, 577, 

589 
Savine, a cause of abortion, 343 
Schmorl's theory of eclampsia, 538, 539 
Schneiderian membrane, development of, 

105 
Sea voyages, effect of, on menstruation, 127 
Secretion, vaginal, in labor, 201 
Secundines, retained, post-partum hemor- 
rhage from, 527 
Semicircular canals, development of, 102 
Seminiferous tubules, 110 
Senses, special, of new-born child, 268 
Sepsis, bacillary, 589 

following abortion, treatment of, 355 

in abortion, 350 

treatment of, 355 

in ectopic gestation, 381 

in newborn child from umbilical infec- 
tion, 641 

puerperal, treatment of, 619 
Septa, urethro-vaginal, 44 
Septic infection a cause of puerperal insan- 
ity, 477 
Septum, inferior, in embryonic circulation, 91 

recto-vaginal, 29 

superior, in embryonic circulation, 99 

urethro-vaginal, 29, 43 

vesico-vaginal, 29 
Serum, anti-streptococcus, in puerperal in- 
fection, 624 
Sewer-gas, infection from, 598 
Sex of fcetus, determination of, by heart- 
sounds, 134 
Sexual gland, 110 

organs, development of, 44, 110 
Shock, foetal, in diagnosis, 138 
Shoulder, anterior, location of, 216 

delivery of, in normal labor, 206 

presentation of, 483 
Signs of pregnancy. See Pregnancy, diag- 
nosis of. 
in diagnosis, Hegar's, 140 
Jacquemin's, 139 
Jewett's, 139, 140 
Silkworm-gut suture in vaginal repairs, 654 
Sinciput, 177 
Sinus rhomboidalis, 80 

terminalis, of placenta, 88 

uro-genital, 111 

venosus, 91, 94 
Situs transversus, 337 
Skeleton, development of, 113 
Skin, changes in, due to pregnancy, 124 

diseases of, in foetus, 339 

following labor, 257 

of newborn child. 271 

pigmentation of, during pregnancy, 128 
Skull, unduly ossified, cause of dystocia, 487 
Sleep in pregnancy, 153 
Smegma, secretion of, 19 
Smellie grasp in pelvic presentations, 478 

-Veit method of manual extraction, 478 
Solutions, antiseptic, 229 
Somatopleure, development of, S2 
Souffle, funic, in diagnosis, 137 



782 



INDEX. 



Souffle, placental, in ectopic gestation, 378 

uterine, in diagnosis, 137 
Special senses in newborn child, 268 
Spermatozoon, fertilization of ovum by, 76 
Sphincter ani, repair of rupture of, 657 
retraction of torn ends of, 657 
rupture of, 656 
vaginas, 21 
vesicae, 43 
Spina bifida, 627 

accompanying hydrocephalus, 489 
cause of dystocia, 489 
treatment of, 628 
Spinal canal at first month, 114 
column of newborn child, 267 
cord, columns of, 98 
development of, 98 
filum terminale of, 98 
fissures of, 98 
injuries to, at birth, 630 
neural canal of, 98 
Splanchnopleure, development of, 82 
Spleen, anomalous position of, 331 
during pregnancy, 123 
foetal, lesions of, 337 
Spondylolysis in transverse presentation, 486 
Spondylotomy in transverse presentation, 486 
" Spontaneous evolution", 483 
rare variety of, 483 
rupture of uterus, 509 
version, 482 
Sprue. See Thrush. 

Staphylococcus in puerperal infection, 585 
Steam sterilization, 228 
Stenosis, anal and rectal, 629 
Sterilitv, diabetes a cause of, 562 
Sterilizer, Arnold. 229 
Sterno-cleido-mastoid, hematoma of, at birth, 

630 
Stethoscope in abdominal examination, 137 
Stimulants in post-partum hemorrhage, 530 
Stomach, anomalous development of, 331 
development of, 105 
infantile, capacity of, 291 
of newborn child, 269 
Strait, inferior, 162 

superior, 162 
Streptococcus erysipelatus, 598 

in puerperal infection, 598 
pyogenes, in puerperal infection, 584 
Striation of abdomen in pregnancy, 132 
Strychnine in puerperal infection, 622 
Subcutaneous injections of salt solution, 532 
Submammary bursas, 66 
Sugar, human vs. cows' milk, 279 

in milk, effect of sterilization upon, 287 
in urine following labor, 255 
Sulphoual in puerperal insanity, 582 
Superfecundation. 301 
Superfcetation, 301 
Superficial perineal fascia, 33 
Superior strait, 162 
Supernumerary nipples, 567 
Suppression of menses, diagnostic value of, 

126 
Suprarenal capsule, development of, 109 
Suture of uterus in Cesarean section, 740 

silk, use of, 657 
Sutures, buried catgut, use of, 657 
of foetal head, 175 

coronal, 175 
lambdoidal, 175 
sagittal, 175 



Sylvius, aqueduct of, 97 
Symphysiotomy, 743 

after-treatment of, 755 

closure of wound in 753 

contraindication to, 747 

defined, 744 

history of, 744 

indication for, 746 

in connection with craniotomy, 734 

in flat pelvis, 437 

in tumors of pelvis, 445 

methods of rest following, 754 

mortality of, 745 

objections to, 746 

present status of the operation, 746 

rationale of the operation, 747 

technique of the operation, 747 

value of, compared with forceps and 
version, 721 

with contracted pelvis, 429 

with flat pelvis, 436 
Symphysis pubis, 162 

rupture of, 512 

causes and diagnosis of, 512 
prognosis and treatment of, 513 
Synclitism, 203 
Syncope, 518 

in pregnancy, 406 
Syphilis, adherent placenta from, 672 

congenital, a cause of icterus, 640 
Colles' law, 643 
treatment of, 644 

in foetus, 337 

of decidua, as cause of abortion, 344 

of placeuta, 314 

TABLE, human and cows' milk compared,. 
281 
Tachycardia, foetal, 336 
Talipes, centric, 338 

Tampon, cervical, in "accidental hemor- 
rhage," 526 
in placenta prsevia, 521 
in abortion, 353 
of uterus, in post-partum hemorrhage, 

531 
vaginal, for induction of premature la- 
bor, 670 
in inducing abortion, 665 
in accidental hemorrhage, 526 
in placenta prsevia, 520 
to induce abortion, 665 
Tansy, ecbolic action of, 663 
Tarnier's bag, 521 
incubator, 296 
Taxis in repositing inverted uterus, 505 
Teeth, caries of, during pregnancy, 405 
Temperature after labor, 255 

causes of rises of, in puerperium, 610 
chart, 226 

during puerperium, 255 
Temporal fontanelle, 176 
Tents for dilatation of cervical canal, 670 
Testis, development of, 110 
time of descent of, 116 
Tetanus neonatorum, 642 
treatment of, 642 
uteri, 417 

diagnosis, 417 

prognosis and treatment of, 418 
Thorax of newborn child, 268 
Thrombosis following abortion, 668 
of vagina and vulva, 513 



IXDEX. 



783 



Thrombosis of vagina and vulva, etiology 
and symptoms of, 514 
treatment of, 514 
Thrush. 644 

symptoms and treatment of, 645 
Thyroid gland daring pregnancy, 123 
Tongue, development of, 105 
Tonsils, development of. 104 
Torticollis in breech delivery, 472 
Toxiemia. of pregnancy, 394 

theory of, in puerperal eclampsia, 538 
Trachea, development of. 107 
Tragus, development of, 103 
Transfusion in post-partum hemorrhage, 

532 
Transverse presentation, 480 
causes of, 480 
diagnosis of, 481 
dorso-anterior position, 481 
frequency of, 480 
management of, 484 
methods of spontaneous delivery, 
spontaneous evolution, 483 
version, 482 
operative procedures, 484 
positions, 481 
prognosis of, 482 
varieties of. 480 
Traumatism as cause of abortion, 342 
detachment of placenta from, 524 
Trendelenburg posture in performing ver- 
sion, 713 
in reposition of cord, 500 
Triangular ligaments, anatomy of, 34, 37 
Triple monsters, 330 
Triplets, 496 

management of labor, 302 
Truncus arteriosus, 91 
Tubal pregnancy, 360 

Tube, Fallopian, changes in ectopic gesta- 
tion, 365 
conditions of, causing ectopic ges- 
tation, 364 
hemorrhages in, in ectopic gesta- 
tion, 368 
low insertion of, a cause of pla- 
centa prrevia, 517 
Tubercular infection in newborn child, 643 
Tuberclosis, as a cause of pelvic deformity, 
422 
cause of abortion, 342 
foetal, 337 

in newborn child, 643 
maternal, contraindication to nursing, 
274 
Tubules of Wolff, 109 
Tubuli lactiferi, 67 
Tumors affecting pelvis, 444 

fcetal, obstructing labor, 492 
of placenta, 314 

solid, of vagina or vulva, cause of dys- 
tocia, 460 
ovarian, obstructing labor, 461 
Twins, 493 

arrangement of membranes, 300 

head and breech presenting, treatment 

of, 495 
in ectopic gestation, 391 
interlocking, 494 

treatment of, 494 
locked, decollation in, 733 
management of labor, 302, 493 
pregnancy, dyspnoea from, 124 



Twins, pregnancy, with prolapsus funis, 498 

relation of, to labor, 493 

sex of, 300 
Tympanites vs. pregnancy, 146 
Typhoid fever in puerperium, 612 

ULCERS, puerperal, 591 
Umbilical cord, development of, 86 
formation of, 86 
hernia, 638 
hemorrhage, 638 
infection, 640 
vegetations, 638 
Umbilicus, infection of, in newborn child, 
640 
vegetations of, in child, 638 
Unguentum Crede in mastitis, 573 
Urachus, development of, 109 
Urea, estimation of, during pregnancy, 154 
excretion of, in pregnancy, 542 
importance of testing for, 211 
test for, Bartley's, 212 
Ureters, course of, 56 

development of, 109 
Urethra, anatomy of, 43 
development of, 113 
Urethro- vaginal septum, 44 
Urinary solids, 211 

system, changes due to pregnancy, 125 
in newborn child, 270 
Urine, changes in, after labor, 255 
condition of, in eclampsia, 538 
during pregnancy, 154 
examination of, 211 

before operation, 738 
during pregnancy, 211 
in pregnancy, 542 
in puerperium, 255 
of newborn child, 271 
retention of, from pressure on ureters,. 

540 
solids in, estimation of, 211 
suppression of, in puerperal eclampsia, 
540 
Urogenital sinus, formation of, 111 

system, development of, 107 
Ustilago maidis, 663 
Uterine adnexa during pregnancy, 121 

contractions affected by hemorrhage, 
524 
causes of, 193 
effect of, on placenta, 671 
excessive, treatment of, 511 
hour-glass, 674 
intermittent, 195 
involuntary, 195 
methods of promoting, 663 
peristaltic character of, 195 
stimulation of, 529 
discharge, examination of, in ectopic 

gestation, 379 
gestation, concurrent with ectopic, 391 
incision in Cesarean section, closure of, 

740 
membranes, development of, 82 
mucosa during puerperium, 253 
Utero-abdominal gestation, 392 
Utero-placental circulation, 87 
Utero- vaginal canal, development of. Ill 
Uterus, action of segments of, in labor. 197 
anatomy of, 57, 172 

anteflexion of, resembling pregnancv, 
143 



784 



INDEX. 



Uterus as a part of parturient canal, 172 
atony of, 307 

atresia of cervix, cause of dystocia, 453 
bicornis, cause of dystocia, 453 
blood-supply of, 55 

bulging of body of, in pregnancy, 140 
carcinoma of, cause of dystocia, 458 
changes in, caused by pregnancy, 85 
cervix, 121 
position, 119 
properties, 120 
shape, 117 
size, 117 
structure, 118 
during menstruation, 71 
ectopic gestation, 365 
following fecundation of ovum, 85 

labor, 251 
from child-bearing, 59 
in labor, 158 

properties of, during pregnancy, 120 
shape and size in contraction, 158 
compressibility of, lower segment of, 

140 
contraction of. following Csesarean sec- 
tion, 740 
during labor, 157 
date of appearance of signs of preg- 
nancy, 143 
density, variations of, 142 
development of, 111 
developmental anomalies, a cause of 

dystocia, 453 
dilatation of, in foetus, 491 
disinfection of, after abortion, 355 
displacement of, a cause of abortion, 343 

during puerperium, 25.1, 265 
distention of, a cause of onset of labor, 

195 
duplex, 325 

early changes of, in diagnosis, 140 
elasticity of, in pregnancy, 142 
emphysema of, 487 
examination of, after Csesarean section, 

742 
fallacies in examination of, 143 
fibroma of, vs. pregnancy, 147 
fixation of, a cause of abortion, 343 
furrows or folds of, 142 
growths of; a cause of rupture, 508 
h?ematometra of, vs. pregnancy, 148 
hvperaemia of, resembling pregnancy, 

^143 
increase in size of, during pregnancy, 

142 
indication for removal of, 743 
inertia of, 412 
causes of, 413 

diagnosis and prognosis of, 414 
in post-partum hemorrhage, 527 
symptoms, 413 
treatment of, 415 
injuries to, in forceps operation, 681 
inversion of, 501 
degrees of, 503 
diagnosis of. 502 
etiology of, 502 
prognosis of, 504 
secondary hemorrhage from, 534 
symptoms of, 503 
treatment of, 504 
prophylaxis, 504 
reposition, 505 



Uterus, inversion of, varieties of, 501 
inverted, reposition of, 504 
involution of, 252 

after abortion, 349 

in ectopic gestation, 364 
irritable, in labor, 417 
isthmus of, 57 
laceration of lower segment of, in rapid 

delivery, 547 
latero-versiou of, 456 
ligaments of, 62 
longitudinal fibres of, 198 
lower segment of, after labor, 210 

in transverse presentation, 482 
lymph-sxjaces of, 58 

malpositions of, causes of dystocia, 455 
masculinus, 110 
massage of, in post-partum hemorrhage, 

532 
measurements of, at different periods of 

pregnancy, 117 
mensuration of, in determining date of 

labor, 150 
method of making cultures from, 613 

of removal in Porro operation, 743 
micro-organisms of, 600 
motor centres of, 157, 193 
muscle-cells of, 252 
muscular structure of, 59 

tissue of, 57 
neiwes of, 252 
new growths of, 456 
normal measurements of, 57 
palpation of fundus of, in diagnosis, 132 
perforation of, in curettage, 357 
peritoneal covering of, 210 
position of, 46 

during pregnancy, 119 
prolapse of, dystocia, 456 

following symphysiotomy, 744 
retraction of, after labor, 209 

in labor, 196 
retroflexion of, an indication for induc- 
tion of abortion, 662 
retroversion of, in abortion, 350 

resembling pregnancy, 143 
rigidity of os and cervix in labor, 417 
round ligament of, anatomy of, 18 
rupture of, 506 

before second stage of labor, 507 

complete, 506 

danger of, in placenta prsevia, 559 

diagnosis of, 509 

etiology of, 507 

exciting causes of, 508 

frequency of, 506 

incomplete, 507 

indications for forceps in, 680 

in hydrocephalus of foetus, 490 

in rapid delivery, 549 

in spasmodic contraction, 417 

in transverse presentation, 482 

pathological anatomy of, 506 

predisposing causes of, 507 

prognosis of, 510 

spontaneous, 506 

symptoms of, 498 

traumatic, 506 

treatment of, 511 
operative, 511 
cceliotomy, 511 
drainage, 511 
prophylaxis, 511 



INDEX. 



785 



Uterus, sacculation of, cause of dystocia, 456 
segments of, 172, 195 

action of. causing rupture, 509 

in rupture, 506 
shape of. 117 

in transverse presentation, 4S1 
situation of. after labor, 210 
size of. 117 

in pregnancy, 14:2 
softening of cervix in pregnancy, 143 
sound measurements of, during puer- 

perium. 252 
spasm and irregularity of, in labor, 417 
spasmodic contraction of, 417 
strength of contractions of, 159 
structure of, 118 
subinvolution of, after abortion, 350 

resembling pregnancy, 143 
table of comparative measurements of 

multiparous and parous, 251 
tardy involution of, 264 
unicornis, cause of dystocia, 453 
vessels of, 55 

and nerves of, changes during labor, 
253 
with fibromyoma, cause of dystocia, 456 
Utriculus, 102 

VAGTXA. after-treatment in operation for 
deep tears of, 659 

anatomy of, 26 

blood- and nerve-supply of, 55 

bulbs of. anatomy of, 25 

changes in, due to pregnancy, 122 

cysts of, obstructing labor, 460 

deep tear of, method of operating, 657 

development of, 111 

duplex, 325 

during puerperium, 251 

fornices of, 27 

hematoma of, cause of dystocia, 459 
treatment of, 514 

injuries to, in forceps operation, 681 

lacerations of walls of, 251 

length of, 27 

lymphatics of, 55 

micro-organisms of, 601 

purplish hue of, in pregnancy, 139 

shortening of, resembling prolapsus 
uteri, 30 

stenosis of, cause of dystocia, 459 

structure of walls of, 27 

swellings of, obstructing labor, 459 

tumors of, obstructing labor, 460 

vessels aud nerves of, 55 
Yaginal examination in labor, 236 
in placenta prsevia, 518 
in puerperium, 617 
in rupture of uterus, 510 
in trausverse presentation, 482 
secretions, micro-organisms in, 601 

lacerations, combined external and in- 
ternal, 652 
complete tear, 656 
internal, immediate repair of, 

method of operating, 653 
repair of, after-treatment, 655 
superficial external, repair of, 651 

outlet, injury to, in labor, 650 

superficial external tear of, 651 

secretion, 601 

microscopical examination of, 601 

signs in multiple pregnancy, 302 

50 



Vaginitis, puerperal, 591 
A'agino-fixation, influence of, on version, 721 
Valve, Eustachian, 95 
Valves of Houston, 31 
Varices in pregnancy, 406 
Varolian bend of embryonic brain, 96 
Variolius. See Pons Varolii. 
Vasculitis, foetal, 336 
Vas deferens, development of, 110 
Vein, azygos, development of, 94 
iliac, development of, 94 
portal, development of, 94 
pulmonary, development of, 95 
Veins, azygos, 94 
cardinal, 93 
development of, 93 
ductus venosus, 95 
effect of, in pregnancy, 128 
hemiazygos, 94 
hepatic, 94 
iliacs, internal, 94 
jugular, 93 
of Fallopian tubes, 56 
of mammary gland, 69 
of ovaries, 57 
of pelvic floor, 54 
of uterus, 56 
of vagina, 55 
omphalo-mesenteric, 91 
portal, 94 
pulmonary, 95 
sinus venosus, 95 
umbilical, 93 
vena cava, inferior, 95 

superior, 95 
vitelline, 91, 93 
Venesection in pregnancy, 123 
Ventricle, fourth, development of, 98 
Ventro-fixation, influence of, upon version, 

721 
Veratrum viride in eclampsia, 546 
Vermiform appendix, 106 
Version, 701 

artificial, in transverse presentations, 

484 
bipolar, 704 

Braxton Hicks' method, 484 
indications for, 704 
method in placenta prsevia, 523 
of performance, 704 
cephalic, 700 

indications for, 701 
complications of, 720 
dangers of, 702 * 

external, 702 

contraindications to, 703 
favorable conditions for performance of, 

702 
for accidental hemorrhage, 526 
for placenta prsevia, 522 
for prolapse of cord, 501 
for transverse presentations, 484 
in rupture of uterus, 511 
indication for, 468, 490, 511 
influence of posture in facilitating, 721 
internal, 706 

advantages of, 707 
contraindications to, 707 
dangers of. 707 
indications for, 706 
method of operating, 707 
podalic, contraindications to, 701 
in placenta prsevia, 522 



786 



INDEX. 



Version, podalic, extraction in, 716 
indications for, 701 
relative value of, 721 
uterine rupture from, 508 
ventrofixation, and vagino-fixation on, 
721 
Vertebrae, injuries to, at birth, 630 
Vertex, of head, 177 
Vesicle of Purkinje, 74 
Vesico-uterine pouch, auatoniy of, 43 
Vesicular mole, 309 
Vessels of pudendum, 20 
Vestibule, anatomy of, 21 
Viburnum in threatened abortion, 351 
Vigier, modification of milk, 284 
Vinegar in post-partum hemorrhage, 531 
Visceral arches. See Branchial arch. 

clefts. See Branchial clefts. 
Vitelline membrane, 74 

veins, 91, 93 
Vitellus of ovum, 74 
Vitreous humor, development of, 100 
Vomiting of pregnancy, 399 
causes of, 401 
diagnosis of, 402 
induction of abortion in, 662 
pernicious, 402 

diagnosis and treatment of, 402 
stages of, 400 
surgical methods in treatment of, 

403 
symptoms of, 400 
Vulva, anatomy of, 17-26 
connivens, 19 
development of, 113 
hsematoma of, cause of dystocia, 459 

treatment of, 514 
hians, 19 



Vulva, labial abscess of, cause of dvstocia, 
460 
oedema of, cause of dystocia, 459 

obstructing labor, 459 
stenosis of, 459 
thrombosis of, 513 
tumors of, obstructing labor, 460 
varicose veins, cause of dystocia, 459 
Vulvar dressing, 246 

WAGNER, germinal spot of, 74 
Walcher's position, in forceps opera- 
tion, 683 
in labor, 237 
in version, 712 
with contracted pelvis, 429 
with flat pelvis, 435 
Weaning of child, 263 
Weight during pregnancy, 124 
loss of, in puerperiuin, 257 
Wet nursing, 278 
Wharton's jelly, 87 
Whey, preparation of, 279 
" White line," anatomy of, 35 
Wigand-Martin method of manual extrac- 
tion, 478 
Wiring after rupture of svmphvsis pubis, 

513 
Wolff, bodv of, 107 

duct of, 107, 110 
Wolfiian bodies, 107, 110 
anatomv of, 44 
duct of,' 107, 110 
tubules of, 109 
Wormian bones, 177 

ZONA pellncida of ovum, 74 
radiata, 74 



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